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Based on review of the medical record and staff interview it was determined the facility failed to ensure the discharge planning evaluation included an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services. The facility failed to ensure the discharge planning evaluation included the patient's capacity for self-care or the ability of family to provide the required care needed upon discharge for one (#2) of eleven patients sampled.

Findings included:

Review of the medical record for patient #2 revealed the patient was admitted on 9/23/2016. Review of the physician documentation on 9/23/2016 revealed the patient was incompetent to make decisions regarding care. On 9/23/2016 telephone contact with the patient's spouse revealed the spouse agreed to act as the patient's proxy.

Review of the Case Management documentation on 9/24/2016 revealed the patient was assessed for discharge planning. Documentation by the case manager revealed the patient was unable to participate in the assessment.

Review of nursing technician's documentation revealed the patient required assistance for ADLs (Activities of Daily Living) during the admission. Assistance was required for transfers, toileting and eating.

Review of Case Management documentation on 9/26/2016 revealed the case manager spoke with the patient's spouse. Documentation revealed the conversation was to finalize discharge. The case manager documented the patient would return home via facility provided transportation.

Review of the record revealed no evidence the discharge planning included an evaluation of the patient's post-hospital needs or the availability of the services. There was no evidence an evaluation of the patient's capacity for self-care or the possibility of the patient being cared for at home by the spouse. Documentation revealed the patient was discharged home on 9/26/2016.

Review of the medical record for patient #2 revealed the patient was readmitted to the facility on 10/14/2016. Documentation revealed the patient was confused, was refusing to bathe, had an inability to walk or do anything independently and had multiple falls at home. Documentation revealed the patient's spouse was unable to assist the patient following the falls. The spouse was unable to assist with ADLs.

Interview with the Manager of the BH (Behavioral Health) Unit at the time of the record review on 11/02/2016 at approximately 2:30 p.m. confirmed the findings.

Based on medical record review and staff interview it was determined the facility failed to ensure referral for services was made for one (#1) of nine discharged patients reviewed.

Findings included:

Review of patient #1's record revealed the patient was admitted on 8/31/2016 as an involuntary admission. Documentation by the psychiatrist on 8/31/2016 at 5:05 p.m. determined the patient was incompetent to make decisions.

Review of Case Management (CM) documentation revealed the facility was unable to contact a family members.

Review of the record revealed a court appointed guardian advocate was placed on 9/13/2016. On 9/17/2016 documentation by nursing revealed the patient's spouse contacted the facility. On 9/18/2016 nursing documentation revealed the patient's spouse agreed to assume the role of the patient's proxy.

On 9/25/2016 case management documentation revealed a family session was conducted with the patient and spouse. It was agreed the patient could return home with home health services to assist with continued care of the patient. Review of the record revealed no documentation a referral for home health services was implemented.

Interview with the nurse manager on 11/02/2016 at approximately 11:30 a.m. confirmed the findings.