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Based on interviews and document reviews, the facility failed to provide necessary medical information to the receiving facility during transfer of care in 1 of 10 medical records reviewed (Patient #1).

This failure created the potential for a disruption in care after discharge for patients who required continued supportive care.

Findings:

POLICY

According to the policy Discharge Planning and Process, upon discharge responsible caregivers are to be given discharge instructions and medication reconciliation information for follow-up care. Responsible care givers include but are not limited to Skilled Nursing Facility (SNF), Home Health Care (HHC), Assisted Living Facilities (ALF) or Hospice.

1. The facility did not maintain a clear process to ensure medical information was provided to receiving facilities.

a) Medical record review revealed Patient #1 was admitted to the hospital on 08/17/15 from an Assisted Living Facility (ALF) with the diagnoses of gastritis and dementia. The Case Management (CM) Summary Discharge Note showed there was notification made to the HHC agency regarding the patients discharge date and time.

There was no documentation to show the ALF had been notified of Patient #1's discharge time and date and no documentation to show that necessary medical information was provided to the ALF.

b) On 11/04/15 at 10:16 a.m. an interview was completed with the Case Manager (CM #2). S/he stated if a patient lived on a dementia unit at an ALF s/he would make sure the patient was going back to an area which could accommodate the patient's needs. CM #2 stated that on the day of discharge the on duty case manager would call to notify the ALF of the time the patient would be discharged. CM #2 was assigned to Patient #1 on his/her day of discharge and reviewed the medical record. CM #2 recalled there were "numerous communications" from the RN Navigator to the transportation agency. CM #2 further stated s/he could not verify the ALF had been notified of the patient's discharge date and time.

c) On 11/04/15 at 11:30 a.m. an interview was conducted with RN #5. RN #5 stated when discharging a patient to an ALF, a facility-to-facility report should be given by the RN. S/he stated all necessary patient information should be compiled into a discharge packet which would be sent with the patient to the receiving facility. If a patient had dementia, RN #5 stated the CM would usually call the family to notify them of the patient's discharge. RN #5 further stated if the family was at the bedside "I would give them copies of the discharge information."

d) At 11:32 a.m. on 11/04/15 in an interview with the RN Navigator (RN #8), s/he stated ALF discharges were different from a SNF discharge because "we treat an ALF discharge like the patients are going home." RN #8 stated the CM should have been in contract with the facility before the patient was discharged to ensure the patient could return to the facility. RN #8 stated the RN navigator would receive instructions from the CM regarding transfer back to the ALF.

e) On 11/04/15 at 9:11 a.m. the Director of Case Management (CM #1) stated CM would contact the family and the facility and document the information in the CM progress note section of the medical record. S/he also stated the RN could call report but CM would ask the facility if a nurse to nurse report was wanted because "a lot of time the facility just wants the discharge summary." CM #1 further stated the discharge summary should also be placed in the discharge packet that was sent with the patient.

There was no documentation the facility contacted the ALF to provide necessary medical information and pursuant to the facility's policy.