Unsafe Discharge Without Required Medical Equipment and Oxygen
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a cognitively intact resident who required specific medical equipment and services upon leaving the facility. The resident was admitted with multiple diagnoses including DM, bacterial infections, ESRD, hypertension, heart failure, and abnormalities of breathing. The resident’s MDS showed a BIMS score of 15, indicating intact cognition. Physician discharge orders dated 2/19/26 specified that the resident was to be discharged home with post-discharge needs including home health nursing, home health PT and OT, a wheelchair, a shower chair, and oxygen. An existing order from 12/5/25 required continuous oxygen at 4 L/min via nasal cannula related to abnormalities of breathing. Despite these orders, the resident was discharged without the ordered medical equipment. The SSD confirmed that the resident was discharged with physician orders for home health, PT, OT, shower chair, walker, and oxygen concentrator, but no medical equipment was provided to the resident upon or prior to discharge. The discharge summary documentation stated that medical equipment was delivered at bedside and that all oxygen supply was handed over to home health, with explanations given on how to use the oxygen supply, but this conflicted with interviews and other record review indicating that the equipment was not actually provided. The SSD also stated that home health was contacted on the day of discharge and that the home health agency had notified her that the oxygen concentrator would not be available upon discharge, and that the resident’s medical equipment and oxygen concentrator were not delivered to the new residence prior to discharge. Interviews with facility staff further described the failure in the discharge process. RN 1 stated that the facility’s process for discharge was to ensure residents had all medications, education, and medical equipment needed for a safe discharge, and that the resident should not have been discharged without the physician-ordered medical equipment and oxygen concentrator. The SSD stated that the resident had been issued a notice of non-payment and had informed her of plans to rent a room from a friend, but acknowledged that the discharge was not safe and that the resident was not educated on the need for medical equipment or the potential consequences of not having it. The DON and the ADM both stated that facility process required ensuring all needed medical equipment was in place prior to discharge and acknowledged that the resident’s discharge without the ordered equipment was unsafe and not consistent with facility policy and procedure on transfer and discharge, which requires orientation and planning to ensure a safe and orderly transfer or discharge.
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