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Based on interview and record review, the facility failed to follow their policies and procedures for transfer of 1 of 1 patients (#1) resulting in increased risk of decline in the patient's health. The facility failed to:

(A-0821) Reassess patient #1's discharge plan to ensure appropriateness of the the plan prior to transfer to another facility in response to medical assessments.

(A-0822) Involve the patient or family when changing the agreed upon discharge plan from one facility type to another resulting in the patient being involuntarily discharge to a psychiatric hospital without documentation of patient consent or physician certification as required by State statute.

(A-0837) Ensure that necessary medical information was provided at transfer to the accepting hospital.

(A-0843) Reassess and review patient #1's discharge plan to ensure that the plan was appropriate to patient #1's changing needs.

Based on interview, policy and record review, the facility failed to reassess 1 of 1 patient discharge plans (patient #1) in response to medical assessments resulting in transfer to a different facility type than the one discussed with the family and recommended by the treating Psychiatrist and noted in the final discharge order, resulting in increased risk to patient #1's health. Findings include:

1. On 12/27/11, the Chief Nursing Officer (CNO) of the free-standing psychiatric hospital that accepted patient #1 from the transferring acute care hospital (at 0009 hours on 11/19/11) left a phone message stating that the patient information provided by the transferring hospital (McLaren) was not sufficient for their facility to make an informed decision on accepting patient #1. The CNO stated that they would not have accepted patient #1 if they had been made fully aware of the complexity of his medical care needs. The receiving facility transferred the patient to another acute care hospital on 11/19/11. Afterward, they received a from phone call from that facility indicating that the patient had a very poor prognosis and was not likely to survive emergency surgery.

2. On 1/3/12 at 1400 hours, during an on-site visit to the hospital that transferred patient #1, at 2223 on 11/18/11 (McLaren), the facility policy titled "Inpatient Transfer," #PC-117, dated 6/12, was reviewed. The policy states:
"Physician identifies need to transfer patient from (facility) based on medical necessity or patient/family request"

3. On 11/17/11 at 1904 hours, a note by Case Manager #1 states: "Dr. #1, Hospice rep... and ...cm (Case Manager) had a long discussion with family regarding hospice...family to discuss and anticipate hospice to ecf (extended care facility) in am."

4. On 11/18/11 at 1000 hours, a note by Psychiatrist #1 states: "patient is very dangerous to himself since his medical condition, aortic dissection and lower oxygen saturation (88% without oxygen...patient needs supervised care...If patient needs oxygen, he should not go to psychiatry. Nursing home or hospice are appropriate for the patient...Patient is psychiatrically stable." (This was the last physician progress note or assessment prior to transfer.)

5. On 1/18/11 at 1118 hours, a note by RN #1 states: "CM had previously spoken with SW#1 re: message from Float CM (Case Manager) re: possible ECF with Hospice. Per her, no ECF will take pt (patient) with psych issues, no insurance and Hospice."

6. On 11/18/11 at 2125 hours, the final discharge order by Dr. #2 states: "...OK to transferred to nursing home as per Dr..."

7. On 11/18/11 at 2223 hours, per the EMS Patient Care Report, patient #1 was transferred to a Free-standing psychiatric hospital.

The above findings were reviewed with the Director of Regulatory Compliance.

Based on interview and record review, the facility failed to involve 1 of 1 patients (patient #1) before changing the discharge plan agreed to in a family/team meeting resulting in patient #1 being involuntarily discharge to a psychiatric hospital without documentation of patient consent or physician certification, as required by State statute. Findings include:

1. On 11/17/11 at 1904 hours, a note by Case Manager #1 states: "Dr.( #1), Hospice rep and ...cm (Case Manager) had a long discussion with family regarding hospice...family to discuss and anticipate hospice to ecf (extended care facility) in am."

2. On 11/18/11 at 1000 hours, a note by Psychiatrist #1 states: "patient is very dangerous to himself since his medical condition, aortic dissection and lower oxygen saturation (88% without oxygen...patient needs supervised care...If patient needs oxygen, he should not go to psychiatry. Nursing home or hospice are appropriate for the patient...Patient is psychiatrically stable." (This was the last physician progress note or assessment noted.)

3. On 11/18/11 at 1118 hours, a note by RN #1 states: "CM had previously spoken with SW #1 re: message from float CM (Case Manager) re: possible ECF with Hospice. Per her, no ECF will take pt (patient) with psych issues, no insurance and Hospice."

4. On 11/18/11 2127 hours, RN #2 states: "Call to Regional EMS who will pick pt.up. Pt. and family informed." This is the only documentation of the patient and family being involved or informed of the hospital's change in discharge plans.

5. On 11/18/11 2223 hours, EMS arrived at patient #1's bedside to initiate transfer.

6. On 1/3/12, review of the facility's "Transfer Consent Form," required per facility PC-117, revealed no signature by the patient or family. A note on the form states: "psych pet/cert".on the line for patient signature.

7. Copies of completed, signed documents, required for involuntary admission to a psychiatric facility, could not be located.

The above findings were reviewed with the Director of Regulatory Compliance on 1/3/12 from 1000-1400 hours.

Based on interview, policy and record review, the facility failed to ensure that necessary medical information was provided at transfer to the accepting hospital for 1 of 1 patients (patient #1). Findings include:

1. On 12/27/11, the Chief Nursing Officer (CNO) of the free-standing psychiatric hospital that accepted patient #1 on 11/19/11 left a phone message with the State agency ing indicating that the patient information provided by the transferring hospital (McLaren) was not sufficient for their facility to make an informed decision on accepting patient #1. The CNO stated that they would not have accepted patient #1 if they had been made fully aware of the complexity of the patient's medical care needs. The receiving facility transferred the patient to another acute care facility on 11/19/11. Post-transfer, they documented receiving a report from that hospital indicating that the patient had a very poor prognosis and was not likely to survive emergency surgery.

2. On 1/3/12 at 1400 hours, during an on-site visit to the hospital that transferred patient #1 on 11/18/11 (McLaren), the facility policy titled "Inpatient Transfer," #PC-117, dated 6/12, was reviewed. The policy states:
"Sending physician must identify and contact the receiving physician."
"The nurse assigned to the patient will call report to the receiving hospital's unit. (Call report before sending the patient.)"

3. There was no documentation in patient #1's record indicating that the physician and nursing contacts (noted above) occurred.

4. On 1/3/12 from 1000-1400 hours, review of patient #1's transfer orders revealed no specific orders for the amount/rate of oxygen to be administered. The last physician's order that mentions oxygen, dated 11/18/11 at 1525 hours, states to discharge "with oxygen."

5. The last physician's order before transfer states:
-"To maintain blood pressure SBP (systolic blood pressure) below 120 in view of the aortic dissection and repair."
-"Inform nursing home about the blood pressure controls."

6. The above order, for blood pressure parameters, written at 2125 on 11/18/11, was noted as "copy sent with transfer." Patient #1 was transferred by EMS so there was no evidence of direct communication with the receiving facility.

7. Per facility policy PC-117, the discharging physician is to complete section II of a "Discharge by Transfer" form. This form could not be located.

8. The above findings were verified by the Director of Regulatory Compliance on 1/3/12 from 1000-1400 hours.

Based on interview and policy review, the facility failed to reassess its discharge planning process on an on-going basis. Findings include:

1. On 1/3/12 at 1400 hours, the facility policy titled "Inpatient Transfer" (#PC-117), dated 6/12, was reviewed with the Director of Regulatory Compliance.

2. The Director of Regulatory Compliance verified lack of compliance with this policy, as noted in the above citations and further stated that it is not facility practice to conduct patient transfers as outlined in their current policy.