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Based on record review and staff interview, the facility failed to ensure the the registered nurse implemented the physician ordered plan of treatment for one (#2) of 10 sampled patients.

Findings included:

Patient #2 was transferred to a receiving facility on 2/6/17. The review of the medical records from the receiving facility included notes signed by the emergency room physician at the receiving facility on 2/6/17 at 2:50 p.m. indicating Patient #2 arrived unresponsive to painful stimuli. The patient had an elevated serum sodium level of 165 and was dehydrated at the time of the admission.

The review of the transferring facility record revealed Patient #2 had a normal sodium level of 141 (normal range 136-145 per facility) and a normal chloride level of 105 (normal range 98-107 per facility) at the time of admission on 11/23/16. The creatinine was 1.6 (normal 0.6-1.3 per facility) and BUN was 23 (normal 8-21 per facility). A repeat blood test on 1/25/17, approximately 10 days prior to the patient's transfer, revealed the sodium was elevated to 153, and the chloride was elevated to 119. The creatinine remained unchanged at 1.6 but the BUN was elevated to 45.

The psychiatrist wrote an order on 1/26/17 at 2:33 p.m. to request an internal medicine consultation regarding electrolyte imbalance and mild dehydration.

The detailed review of the medical record with the Director of Behavioral Health Services failed to reveal an internal medicine consultation report in accordance with the physician's order from 1/26/17. There was no evidence the nursing staff had attempted to notify an internal medicine physician of the need to see the patient in consultation.

There was no evidence the nursing staff notified the psychiatrist of the abnormal electrolyte test results dated 1/25/17 who saw Patient #2 multiple times between 1/26/17 and discharge on 2/6/17. There was no evidence the nursing staff notified the cardiologist who saw Patient #2 in consultation on 2/5/17, one day prior to discharge. There was no mention of the electrolyte imbalance in the consultation report dated 2/5/17.

The RN Director of Behavioral Health confirmed the above findings on 3/6/17 at the time of the record review.

Based on record review, policy review and staff interview it was determined the facility failed to reassess the patient's discharge plan for appropriateness of the discharge plan to ensure the needs for one (#2) of 10 sampled patients was met.

Findings included:

The review of the facility policy titled "Case Management Plan for Discharge Planning Policy", no policy number, revision date 3/31/14 indicated the discharge plan will reflect the recommendations and contributions of the physician and healthcare team members involved in the patient's care, treatment and services as appropriate.

A review of the medical record for Patient #2 on 3/6/17 revealed "The Behavioral Health Discharge Instructions/Continuing Care Plan" was signed by the Discharge Planner on 2/2/17 at 12:14 p.m. and by the Registered Nurse (RN) on 2/5/17 at 1:20 p.m. The portion of the form initialed by the Discharge Planner indicated Patient #2 would be transferred on 2/6/17 by a non-emergency medical transport company from the facility to another psychiatric facility located 326 miles away .

The form included documentation initialed by the RN indicating Patient #2 could not feed himself or provide personal care without assistance. The patient was unable to manage medications independently. The mobility status was noted as "wheelchair" and "assist". The mental status was documented as "self". There was no evidence the Discharge Planner was aware of the nursing assessment, having signed off on the discharge plan three days earlier.

The patient's vital signs documented on 2/5/17 at 1:20 p.m. were temperature 98.2, pulse 74, blood pressure 147/86 and respirations 17. The review of the record failed to reveal the Discharge Plan was updated with vital signs performed prior to the actual discharge of the patient on 2/7/17 at 7:15 a.m.

The nurse's notes dated 2/6/17 included documentation Patient #2 was administered an anti-anxiety medication by injection at 5:56 a.m. The record failed to reveal evidence of the reassessment of Patient #2 to determine the response to the medication. The notes included Patient #2 departed the facility at 7:15 a.m. by stretcher.

The review of the record failed to reveal evidence of discussion of the discharge plan with the nursing staff or the physician or the approval of the plan to transport Patient #2 by non-emergency transport by the physician.

The receiving facility's Emergency Room Nurse's Notes dated 2/6/17 at 2:50 p.m. and signed by the RN (Registered Nurse) included Patient #2's temperature was 100.6 F (Fahrenheit) and the oxygen saturation was 92% on room air. The RN documented Patient #2 had a Stage I decubitus ulcer on the coccyx and sacrum present on admission. Patient #2 was unresponsive. Rubs were heard in both lungs with poor air exchange.

At 4:10 p.m. the patient's vital signs included the patient's temperature had increased to 101.7 F Patient #2 opened the eyes in response to painful stimuli. Patient #2 was found to have a large formed mass of stool present in the rectum requiring digital disimpaction. The patient subsequently required intubation.

An interview was conducted with the MSW (Master's Degree in Social Work)/Discharge Planner and the RN Director of Behavioral Health Services on 3/7/17 at 1:45 p.m. When asked how she determined the non-emergency medical transport would be able to meet the patient's needs during the extended travel time, she asked for clarification. She was informed the surveyor was referring to toileting and the provision of food and fluids. She initially indicated she did not take these considerations into account. She stated when she called the company dispatcher the dispatcher determined the patient's needs by asking multiple questions. The facility was unable to provide any documentation of an agreement or contract between the facility and the transport company detailing what services they would provide to the patients during transport. The Discharge Planner stated she did not know how the transport company would meet the needs of the patient at the time she arranged the transport.