Unsafe Discharge – QAPI Case Study #354
A resident who was admitted to the facility in January for rehabilitation services due to a fractured right wrist was being helped by an elder service agency. The agency was to have her apartment cleaned and ready for her return upon discharge from the nursing home. The resident was discharged in July and returned to the apartment. Staff from the facility visited the apartment for a wellness check and found that it had not been cleaned and was not in livable condition. The resident reported that jewelry and paintings were missing from her apartment, as well as several checks from her checkbook. Facility staff determined that the resident’s situation was not safe for her, and that she had been exploited.
There was no verification before the resident was discharged that the elder service agency had provided the services it agreed to provide, and the resident may also have been exploited by her landlord. The resident was readmitted to the nursing home, with her consent, until a safe discharge could be arranged. Her bank account was checked, and it was discovered that a person unknown to the resident cashed 40 checks from her account. The bank reimbursed the resident’s funds and set up new accounts for her. The resident believes that her landlord took her money.
The bank notified the police, and a representative from the bank visited the resident at the facility. A representative from the elder service agency was scheduled to meet with the facility administrator; however, the administrator reported them for failing to ensure that the apartment was cleaned and ready for the resident. Another elder service agency will be contacted and requested to conduct an inventory of the apartment and take pictures.
Facility staff do not think it is safe for the resident to return to the same apartment with the same landlord. She will not be discharged until safe arrangements are made. Staff were educated and trained in the process for ensuring that a resident is discharged into a safe environment. A home visit pre-discharge will be conducted for future discharges to home.
