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Based on staff and family interview, skilled nursing facility sstaff interview, review of policies and procedures, and medical record review, the facility failed to implement a plan of care that included following all procedures in their discharge planning post evaluation process for 1 of 10 sample patients (#1) reviewed for discharge planning. The findings were:

Review of the physician's progress notes, dated 1/6/19, showed patient #1 was admitted on 1/5/19 due to altered mental status. This review also showed the physician anticipated the patient "will not be able to return home but may benefit from a skilled stay prior to long term placement". On 2/26/19 at 8:52 AM interview with a family member revealed when staff talked with the family about discharging the patient, the family member asked the hospital to make arrangements for discharge to skilled nursing facility #1, because the location made it possible for family to visit frequently. The family member stated the hospital discharged the patient to skilled nursing facility #2 on 1/9/19 without first contacting the desired facility or talking with the family about available options.

Interview on 2/21/19 at 1:37 PM with skilled nursing facility #1 administrator and social services director revealed the hospital did not contact them prior to discharging the patient. Review of the medical record showed no evidence the hospital staff talked with the family member about discharge to skilled nursing facility #1, nor was there evidence of contact with the facility prior to the discharge. Further review showed no evidence the hospital gave the patient and family a list of skilled nursing facilities that were available. Interview on 2/21/19 at 4:08 PM with the hospital case management nurse revealed she contacted skilled nursing facility #1 before the patient was discharged; and the facility was unable to accept the admission. However, during the interview the hospital case management nurse verified the contact and her conversation with the family member regarding skilled nursing facility #1's response were not documented in the medical record.

Review of Policy 978, Version 5, titled "Care Coordination Discharge Planning", revised 12/18/18, showed the following procedures were included in the discharge planning post evaluation process:
a. "Make arrangements and referrals as appropriate to patient needs".
b. "Document activities related to discharge planning in the patient's medical record".
c. "Include in the discharge plan a list of the Home Health Agencies (HHAs) or Skilled Nursing Facilities (SNFs) that are available to the patient, that are participating in the Medicare program, and that service the geographic area (as defined by the HHA) in which the patient resides, or in the case of a SNF, in the geographic area requested by the patient... Document in the patient's medical record that the list was presented to the patient or to the person acting on the patient's behalf".