HospitalInspections.org

Based on facility policy, medical record review, review of emails, and staff interviews, it was determined that the facility failed to ensure that one patient (P)(P#1) out of four sampled (P#2, P#3, P#4) was accepted by a Skilled Nursing Facility prior to transferring the patient to the facility.

A review of the "Discharge Planning and Continuing Care" policy #10.001, reviewed 8/22, revealed the purpose of the policy was to ensure that a systematic process addressed the need for continuing care, treatment, and services after discharge. Discharge planning would begin at admission and would be the joint responsibility of the interdisciplinary team. A social worker would arrange specific therapeutic placements and involve family as appropriate. The social worker would be responsible for the development and coordination of the discharge plan and safety plan. The social worker would coordinate with the family and community resources to provide optimum implementation of the discharge plan.

A medical record review revealed that Patient (P) #1 was admitted to the Behavioral Health Unit on 9/27/23 from a Skilled Nursing Facility (SNF). A Psychosocial Assessment by Social Worker (SW) AA on 9/28/23 at 11:21 a.m. revealed that P#1 was referred to the unit for increased aggression with psychosis due to organic brain disease (dementia). P#1 lived at a nursing home, and the Director of Nursing said P#1 would not be returning to the nursing home. However, placement had been secured by the SNF, and P#1 would be transitioned to a memory care unit.

A review of a note by SW AA on 10/6/23 at 10:50 a.m. revealed that P#1 wanted to return to his previous living situation. SW AA contacted the Director of Nursing to bring awareness of P#1's discharge, and assisted P#1 in setting up transportation.

A review of Discharge Instructions by the Registered Nurse (RN) BB on 10/10/23, revealed that P#1 would be released to a nursing home via Medicaid transportation.

A nursing note by RN BB on 10/10/23 at 12:30 p.m. revealed that P#1 left the unit at 12:30 p.m. in a wheelchair and was assisted into the transport van. A nursing note at 12:45 p.m. revealed that RN BB tried to call a report to the nursing home and was transferred to a voicemail. A message was left for the nursing home to return the call regarding P#1.

A review of emails to and from the Social Worker (SW) AA and the Director of Nursing at the SNF revealed the following:

" 10/4/23 at 1:02 p.m.: the DON was notified by SW AA that P#1 would be discharged on 10/6/23.

" 10/4/23 at 1:08 p.m.: SW AA acknowledged that someone would come from the memory care unit to assess P#1, and SW AA provided directions.

" 10/9/23 at 9:39 a.m. The memory care facility requested paperwork to be completed prior to P#1 being accepted at the memory care unit, including a Power-of-Attorney (POA). The name and telephone number of a family member who had agreed to be POA was provided in the email.

" 10/9/23 at 1:17 p.m.: SW AA notified the DON that both attempts to reach the POA were unsuccessful, and as a result, P#1 would be discharged on 10/9/23, and the facility could no longer hold him.

" 10/9/23 at 12:49 p.m.: Per a telephone call, the DON had notified SW AA that P#1 could not be released to the nursing home safely. Discharging P#1 under the known circumstances would be unsafe. P#1 required discharge to a memory care unit and needed a Power of Attorney. A family member would assist.

An interview took place with the Social Worker (SW) AA on 10/24/23 at 1:15 p.m. in the Conference Room. SW AA said that on the date of discharge, the memory care unit said they did not realize how far the drive was, and they would not make it to pick up P#1. The following Monday, 10/9/23, SW AA tried unsuccessfully to locate a family member to be the POA and told the DON that P#1 would be discharging back to the nursing home. SW AA called a local transportation company to take P#1 back to the nursing home. When the driver arrived at the nursing facility, a staff member came out of the building and said P#1 was not getting out of the van. The driver called SW AA, who advised the driver to call an ambulance. The DON tried to block the transport driver from leaving the facility and was running behind the van. The ambulance took P#1 to the Emergency Department.

An interview took place with the Registered Nurse (RN) CC on 10/24/23 at 2:18 p.m. RN CC said the nursing home did not want to take P#1 back. The ombudsman got involved and told the nursing home they had to take him back. RN CC called the nursing home and was told she had to talk to the nurse manager. RN CC left a voicemail, but the manager did not return the call.