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Based on document review and interview, nursing staff failed to complete the Transport/Transfer Order Form and lacked documentation of a nurse to nurse phone report with the accepting facility for 9 of 10 (patients 1, 2, 3, 4, 6, 7, 8, 9, and 10) medical records reviewed.

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner in regards to patient transfers.

Based on document review and interview, nursing staff failed to complete the Transport/Transfer Order Form and lacked documentation of a nurse to nurse phone report with the accepting facility for 9 of 10 (patients 1, 2, 3, 4, 6, 7, 8, 9, and 10) medical records reviewed.

Findings include:

1. Facility policy titled, "Transfer of Patient", PolicyStat ID 10623375, last reviewed 06/2023, indicated that the following information shall be completed when transferring the patient: transfer order and the nurse shall conduct a Nurse to Nurse phone report with the accepting facility and document the report in the nurse's notes.

2. Review of the medical record transfer documentation for patients 1, 2, 3, 4, 6, 7, 8, 9, and 10's lacked documentation of the Transfer/Transport Order Form and of a nurse to nurse phone report with the accepting facility.

3. Interview with A1 (Chief Executive Officer), A2 (Director of Clinical Services), and S1 (Registered Nurse and Nursing Supervisor) on 04/04/24 at approximately 4:00 p.m. all confirmed Patients 1, 2, 3, 4, 6, 7, 8, 9, and 10's medical record lacked documentation of the Transfer/Transport Order Form and the Form should be completed and placed in the patient's medical record.

Based on document review and interview, social services failed to complete timely progress notes for 4 of 10 patients. (patients #1, #2, #3, and #7)

Findings include;

1. Review of patient #1 medical record (MR) indicated the patient was admitted on 1/2/24 and discharged on 3/7/24. The MR lacked social services progress notes after 1/25/24.

2. Review of patient #2 MR indicated the patient was admitted on 1/2/24 and discharged on 2/9/24. The MR lacked social services progress notes after 1/26/24.

3. Review of patient #3 MR indicated the patient was admitted 1/3/24 and discharged 1/24/24. The MR lacked social services progress notes after 1/8/24.

4. Review of patient #7 MR indicated the patient was admitted on 1/11/24 and discharged on 3/1/24. The MR lacked social services progress notes after 1/18/24.

5. Staff member #A1 (Chief Operating Officer) and staff member #S1 (Registered Nurse and Clinical Supervisor) verified in interview on 4/4/24 at approximately 4:00 p.m. the medical records lacked social services progress notes for above patients.

Based on document review and interview, the facility failed to document complete Social Services progress notes related to discharge in 7 of 10 (patients 1, 2, 3, 4, 5, 7, and 9) medical records reviewed.

Findings include:

1. Facility policy titled, "Discharge Planning", PolicyStat ID 10827863, last approved 12/2021, indicated the social worker documents discharge information on social service notes and the Master Treatment Plan.

2. Review of Patients 1, 2, 3, 4, 5, 7, and 9's medical records lacked discharge information in Social Services progress notes.

3. Interview with A1 (Chief Operating Officer), A2 (Director of Clinical Services), and S1 (Registered Nurse and Clinical Supervisor) on 04/04/24 at approximately 4:00 p.m. confirmed Patients 1, 2, 3, 4, 5, 7, and 9's medical record lacked discharge information in the Social Services progress notes.

4. Interview with A2 at approximately 4:00 p.m. confirmed Social Services should document all patient and family interactions and discharge planning in the Social Services progress notes.