Failure to Provide Caregiver Training Prior to Planned Home Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective discharge planning and caregiver training prior to a planned discharge home. The resident was admitted with hypertensive heart disease with heart failure and morbid obesity, and MDS assessments showed the resident was cognitively intact but required partial/moderate assistance for toileting hygiene, bathing, dressing, footwear, bed mobility, and toilet transfers. Case management notes documented that the resident and the designated DPOA agreed the resident would return home, with assistance from a family member and a close friend for ADLs, mobility, personal care, meals, and supervision. A physician order set a discharge date to the resident’s home, and the physical therapist recommended home health, a caregiver, bariatric front wheel walker, wheelchair, and oxygen upon discharge. Despite these identified needs and the plan for home discharge with caregiver support, there was no documented evidence that caregiver training was provided to the responsible party or any designated caregiver prior to the planned discharge date. There was also no documentation that caregiver training was rescheduled when it was not completed before the planned discharge. On the planned discharge day, the CNA confirmed the resident required assistance with daily activities, and the responsible party reported uncertainty about being able to provide the necessary care after discharge. The DOR confirmed there was no documentation of caregiver training or appointments to coordinate such training, and the CM stated caregiver training had been offered but not completed. The DON stated that rehab was responsible for caregiver training for ADLs and that the caregiver or any designated caregiver should have been trained to ensure a safe discharge home, and that without completed caregiver training, discharge home would not be considered safe. The facility’s discharge policy required discharge planning to ensure a safe transition and to determine if appropriate and adequate support, including caregiver capacity, was in place.
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