Washington Ctr For Aging Svcs

Based on record view, staff interview and family interview, the facility failed to implement its discharge planning process to ensure a safe discharge for one (1) of three (3) sampled residents that were discharged home. (Resident #221)The findings included:Resident #221 was admitted to the facility on [DATE] multiple diagnoses including Chronic Respiratory Failure, Morbid Obesity, and Sleep Apnea.A policy titled, Discharge Planning with an Interdisciplinary Team review date of 01/03/24 documented, The social worker (discharge planning coordinator) will counsel resident and family about available .services. An admission Minimum Data Set assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status summary score of 15 indicating the resident had an intact cognitive status.

The resident was coded for using a wheelchair, requiring substantial to maximum assistance with upper body, total assistance for lower body, partial to moderate assist with mobility, total assist with bathing, and incontinent of both bowel and bladder.

The resident was also coded for receiving physical therapy, occupational therapy, and oxygen therapy. A nursing Discharge summary dated [DATE] documented in part, Resident completed rehab therapy successfully and is scheduled for discharge on Saturday 06/07/25.

Resident will continue to receive Physical Therapy/Occupational Therapy/Home Health services in the community.

Resident continues on oxygen therapy at 2 liters per minute via nasal cannula for shortness of breath. A discharge nursing progress note dated 06/07/25 at 3:37 PM documented, Resident discharge home this morning at 12 noon.

She was signed off by her daughter.

Medication and discharge teaching provided patient verbalized understanding of teaching.

She went home with facility oxygen cylinder daughter promise to return cylinder. A District of Columbia complaint intake dated 06/24/25 documented in part, My mother [Resident #221's name] was discharged from rehab.

The rehab didn't even have operable transport oxygen for her to go home with.

The social worker.stopped answering our call after my mom was discharged .

She assured us that she would have wrap around services to help with our mom after discharge.

During a telephone interview at 1PM on 08/07/25, the complainants stated that because Employee #41 did not coordinate home care services, physical therapy services, and occupational therapy services prior to their mother's discharge on [DATE]s.

The employee told them she would make sure the resident receives those services.

However, the services were never provided.

They also stated they called the employee several times, but she failed to return their calls.

The complainants said that they were using an oxygen concentrator that their mom had from 2 years ago.

Additionally, the complainants stated that their mother needed the services because the family member that was providing care for her was wheelchair bound, and the mother has had a couple of falls without injury since discharge.

During a face-to-face interview at 12:09 PM on 08/11/25, Employee #41 (Social Worker/Discharge Coordinator) stated that she verbally requested home care services with a local home care agency that frequently comes into the facility.

However, she did not have documented evidence of that correspondence or if the homecare agency accepted or denied services for the resident.

Additionally, the employee stated that she did not coordinate continuous oxygen therapy services because she was not aware the resident needed oxygen.

During a telephone interview at 2:57 PM on 08/11/25, the representative from the local home care agency stated that he verbally informed Employee #41 that his agency could not provide services for the resident, but he could not remember the specific date.

Additionally, the representative stated that he did not have documented evidence of the denial of services.

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