HospitalInspections.org

Based on review of facility policies and procedures, medical records, and staff interviews, it was determined that the facility failed to ensure that the discharge planning evaluation was discussed with the patient's representative and power of attorney (POA) when one patient (P) (P#5) of four (P#5, P#6, P#7 and P#8) sampled patents was discharged to a personal care home by way of taxi without notification to the family representative.


Findings included:


A review of the facility's policy titled "Patient Bill of Rights," Policy # A&R #17, last reviewed 1/2025 revealed the following:

I. Policy.
It is the policy of this hospital to ensure that all patients receive a copy of the Patient's Bill of Rights form, as well as an oral explanation of those rights and responsibilities, both in their primary language and in simple non-technical terms.

II. Procedure.
1. At the time of admission, each individual shall be provided with a copy of the Patient's Bill of Rights form and a verbal explanation of those rights in their primary language in simple nontechnical language. If a family member, legal guardian, or friend is available, he or she shall be asked to be present during the explanation. This shall be done with both voluntary and involuntary patients.


A review of the facility's policy titled "Discharge Planning," Policy #RNP046, last reviewed 1/2025, revealed the following:

I. Policy.
1. The development of a Discharge Plan begins on admission.

II. Procedure.
1. As a component of the assessment process, treatment recommendations are formulated. These recommendations include the various levels of care indicated to assure the patients are treated at the appropriate level of care.
2. The Discharge Plan Should: (a) Prepare the patient and family for the transition to the next level of care. (b) Address the patient's and family's need for instructions about continued treatment. (c) Delineate how progress made in the current level of care will continue after discharge.
4. In developing discharge aftercare plans, the following is considered as appropriate: a. Family relationships. D. housing needs and/or placement issues.


A review of P#5's medical record revealed that he was admitted to the facility on 10/26/25.


A review of transition record dated 11/4/25 at 10:19 a.m. revealed the discharge disposition was to a group home; Family involvement: yes; Mode of Transportation: Taxi


An interview was conducted with Social Worker (SW) HH on 11/18/25 at 2:10 p.m. in the administration conference room. SW HH stated after reviewing P#5 medical record that he vaguely recalls the patient. He stated that he did not speak with P#5's family representative during his inpatient stay at the facility. SW HH stated that it is the facility's policy to keep the patient's representative, if known, up to date on the process of their family member. SW HH confirmed that P#5's family representative was not notified prior to his discharge back to his personal care home. SW HH confirmed that P#5's family was not given the opportunity to transport him back to his personal care home to avoid P#5 being placed in a taxi. He stated that Discharge Planner (DP) II is new in her position at the facility and failed to contact P#5's family during his admission at the facility.


A telephone interview was conducted with Discharge Planner (DP) II on 11/18/25 at 5:45 p.m. DP II stated that she started at the facility the end of October 2025. She stated that she did recall P#5 during his inpatient admission at the facility. DP II stated that she could not recall reaching out to P#5's family regarding his discharge.


An interview was conducted with the Director of Clinical Services (DCS) KK on 11/19/25 at 12:30 p.m. in the administration conference room. DCS KK stated that she became aware of the situation concerning P#5 when this surveyor entered the facility to investigate this complaint. She continue to explain that after reviewing P#5's medical record she confirmed that communication with his family was not documented. DCS KK continued to explain that the responsibility for continuous communication with the patient's family collectively falls on the interdisciplinary team as a whole. She continued to say that in this case Program Therapist (PT) LL was assigned to P#5 and was responsible for communicating with his family as it relates to his progress in the program as well as plans for his discharge. DCS KK stated that the role of Discharge Planner (DP) also maintains communication with the patient and their representatives when necessary. She continued to explain that the DP is also responsible for communicating with the facilities that refer the patient and/or for patient placement. DCS KK stated that P#5 was accepted back to his personal care home, and this may be the reason communication with his family was not completed. DCS KK confirmed that P#5, who has been diagnosed with dementia, should not have been transported back to his personal care home in a Taxi. She continued to say that PT LL should have reached out to P#5's family and documented the interaction regarding his discharge plan.


An interview was conducted with Program Therapist (PT) LL on 11/19/25 at 1:30 p.m. in the administration conference room. PT LL stated that she vaguely recalled P#5. She continued to explain that as a PT she is responsible for facilitating individual therapy and group therapy with patients and their families. She continued to say that it is important that the PTs and interdisciplinary team to ensure that all patients are stabilized before discharge. PT LL confirmed that she did not communicate with P#5's family during his admission to the facility. She continued to explain that although she did not speak to P#5's family someone had to know his family could not pick him up and that is why a taxi was called to transport him back to his personal care home. PT LL confirmed that there was no documentation in P#5's medical record indicating a call was made to P#5's family or representative regarding his discharge and transportation back to personal care home. She continued to say that she accepts responsibility for not ensuring communication was completed with P#5's representative.