Failure to Coordinate Discharge Planning, Community Services, and Medication Management
Penalty
Summary
Surveyors identified a deficiency in the facility’s discharge planning process related to lack of coordination with community agencies and inadequate medication management for two residents. The facility’s Discharge Policy, revised 12/16/2026, did not address pre-discharge needs such as medication ordering, medication teaching, coordination of home care services, equipment needs, or ensuring follow-up appointments were made before discharge. For Resident 1, who had diabetes and dementia but was assessed as cognitively intact, the Discharge Plan of Care documented that assistance with bathing, toileting, and dressing would be provided by family and personal caregivers, but there was no documentation of medication teaching or follow-up appointments. The Home and Community Services case manager reported they were not notified of this resident’s discharge, so caregivers could not be scheduled, and the family later called with questions about sliding scale insulin administration because they had not received training from facility nurses before discharge. For Resident 2, who had unspecified cognitive impairment, adult failure to thrive, and needed assistance with personal care, the admission documentation included prior hospital case management concerns about safety at home and the family’s ability to provide care. The Discharge Plan of Care stated the resident was cognitively intact and would receive assistance with most ADLs from family, but in-home care was not ordered, medication refills were not sent to a pharmacy, and no follow-up appointment with the primary physician was made. The resident was later readmitted after not receiving care at home and running out of medications about a week after discharge. The Home and Community Services case manager stated they had not been notified of this resident’s discharge and indicated that, based on identified concerns, involvement would have been expected upon referral. The Social Services Director acknowledged not knowing about medication re-ordering or teaching for discharges and reported typically not making follow-up appointments, while leadership staff acknowledged lack of awareness of the coordination issues and that the discharges for these residents were not safe.
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