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Based upon policy and procedure reviews, medical record reviews, and staff interviews, the hospital's discharge planning staff failed to ensure the acceptance and bed availability of an assisted living facility (ALF) prior to discharge for 1 of 1 patients, who was refused admission upon arrival to the ALF after discharge from the hospital (#3).

The findings include:

Review of current hospital policy "Aftercare Plans, Referrals and Placement Assistance" issue date 04/2009, revealed "PURPOSE: To establish a procedure for Aftercare Planning, To ensure that all patients at FRMC receive proper Aftercare Planning so as to reduce and/or avoid readmissions to our facility or other similar facilities. To ensure continuity of patient care. ...To ensure that necessary placements are initiated in a timely manner so appropriate alternative living situation is available to patient at the time of discharge. ...POLICY: ...4. As early as possible in the treatment process, the Unit Counselor will communicate directly with the identified referral source; ..."

Review of current hospital policy "Nursing Home/Rest Home Placements" date revised 05/2009, revealed "PURPOSE: The purpose of the Nursing Home Placements policy is to establish a procedure for skilled nursing home placements or higher level of care placements. PROCEDURE: 1. The unit social worker assesses the need for nursing home or rest home placement upon a patient's admission. ...5. Assess availability of beds - send FL-2 and/or PASARR to homes with beds available. ...10. Send copy of MD orders, diagnostics, H & P, consultations. Send FL-2 and/or PASARR. Call place of transfer and see if they need anything else. ..."

Closed record review on 06/08/2011 for Patient #3 revealed, a 41 year old male, transferred under involuntary commitment to Hospital A's psychiatric campus from the emergency department of Hospital B on 04/13/2011. Record review revealed an admissions diagnosis of Impulse control disorder, not otherwise specified; Mental retardation, which is moderate; and Down Syndrome et al. The patient was subsequently treated and discharged on 05/26/2011.

Review of an admissions history and physical dated 04/13/2011 revealed "...lives in a group home, very poor historian. He is disabled. ..."

Review of a progress note dated 04/15/2011 at 1550 by UC #1 revealed "Spoke with ALF staff where (Patient #3) has lived for the past 5 1/2 months before moving to a group home for 2 days before being hospitalized. ALF & group home will not take him back. ...Message was left for guardian....& case manager (a non-hospital employee, rather a employee of a local management entity - LME)....about placement."

Review of a psychosocial evaluation dated 04/15/2011 (not timed) by Unit Counselor (UC #1) and co-signed by UC #2, revealed "...3. Do you have a place to live? [] Yes [] No If yes, describe where you live: (check mark placed in the NO box) Pt cannot return to the group home (hand written on a line)." Further review revealed "...16. Discharge / After Care Plan Living Arrangement post D/C (discharge): Needs a new placement (hand written on a line)."

Review of a "Treatment Planning Meeting Review/Update" form dated 04/22/2011 (not timed) revealed problem #3, "Continue to work c (with) pt's (patient's) case manager to locate suitable placement + (and) finalize disposition."

Review of a progress note dated 04/26/2011 at 1400 by UC #2 revealed "Message left for pt's case manager to update discharge plans."
Review of a "Treatment Planning Meeting Review/Update" form dated 04/29/2011 (not timed) revealed problem #3, "Discharge plans remain uncertain - have left message for case manager to asses(s) if he has found any placement options."

Review of a "Treatment Planning Meeting Review/Update" form dated 05/05/2011 (not timed) revealed problem #3, "Pt. (patient) cannot return to placement. Case manager is assisting placement search."

Review of a "Treatment Planning Meeting Review/Update" form dated 05/12/2011 (not timed) revealed problem #3, "Pt. cannot return to placement. Case manager has arranged an assessment for a group home & a state facility on the 17th."

Review of a progress note dated 05/13/2011 at 1550 by a Unit Counselor (UC #2) revealed "Call received from pt's case manager stating that pt is scheduled for an admission hearing on Tues(day) 5/17 and pt will be assessed here on Tuesday by a community group home for placement."

Review of a progress note dated 05/18/2011 at 1600 by UC #1 revealed "Spoke with pt's guardian concerning TTP (Treatment Team Plan) update she (guardian) said that pt was accepted at XXX but they do not have an admission date yet. She will let us know hen they have a date."

Review of a "Treatment Planning Meeting Review/Update" form dated 05/18/2011 (not timed) revealed problem #3, "Pt has been accepted at XXX (a state neuro-medical treatment facility) but there is no admission date yet."

Review of a progress note dated 05/20/2011 at 1430 by UC #1 revealed "Left a message for (case manager's name), pt's case manager asking when (Patient #3) would be able to enter XXX."

Review of a "Treatment Planning Meeting Review/Update" form dated 05/23/2011 (not timed) revealed problem #3, "Pt has been accepted at XXX but there is no admission date yet."

Review of a progress note dated 05/23/2011 at 1030 by UC #1 revealed "Spoke with guardian, (name of guardian), & she reported that [name] (pt's case manager) sent an email to NC Start about respite services for (Patient #3) as a transition into XXX will call (case manager name) today."

Review of a progress note dated 05/25/2011 at 1430 by UC #2 revealed "Update regarding pt's placement. Pt's case manager has been working on pt's placement since his admission. Pt has been in multiple assisted living facility and is not appropriate for that level of care. Case manager has stated he contacted multiple group home and none will accept due to behavior and that pt does not have CAP funds. Case manager also contacted ICF/MR facilities and none of them will accept. Case manager has been working on placement at XXX which is the state facility for that part of the state and pt has been accepted and we are waiting for an acceptance date. Please note that pt has exhausted all levels of care and that is why placement at XXX is the only option."

Review of a progress note dated 05/26/2011 at 1350 by UC #2 revealed "Phone contact made with pt's guardian,....Verbalizes understanding the difficulty in identifying an appropriate placement but agreed to placement at (name of ALF) as the only option available. I spoke with (name) at XXX who stated that they will be accepting him (Patient #3) but stated it could be several weeks because they are having to move other residents to make a bed in the cottage identified."

Review of a progress note dated 05/26/2011 at 1630 by UC #1 revealed "Spoke with case manager (name) around 10:30-11:00. The case manager called & said that he found placement for the pt & I needed to fax a FL-2 (state medicaid identification form) & if it is available a TB (tuberculosis) test. He also asked about transportation... I told the case manager I would fax the FL-2 & TB tests & let him know if the Sheriff could pick him (Patient #3) up. I asked if the pt could go to the facility today & he replied 'yes, if they received the FL-2 & TB.' ...I called the Sheriff & they said they could call me when they were on their way. ...I called the case manager back & asked if the placement was an ALF. He replied 'yes'. I asked him for the placements name, address, & phone number. I completed the FL-2....& I faxed it to the given number. The Sheriff called & said they would be leaving in a few minutes. I gave them the address of the placement....I called the case manager & told him that the Sheriff would be here to pick the pt up in a little over an hour. ...I completed the after care plan. ...At around 15:00 I was on the phone & I kept getting beeps. Once I was off the phone the RN told me that the Sheriff was calling me because they were in an ordeal & wanted to know who had discharged the pt. ...I tried calling (name of case manager) & he wouldn't pick up. I called (name of guardian) & she said they were in an ordeal. She (the guardian) thought what had happened was that they accepted him (Patient #3) until they got the FL-2 & saw who it was & then decided not to take him when they showed up. She told me they were on the way to the hospital where the patient came from (Hospital B) & did not know if they would take him."

Review of a progress note dated 05/26/2011 at 1645 by UC #2 revealed "Call received form (county name) Sheriff dept. (department) around 1530 stating that (name of ALF) refused to accept pt for admission when they arrived. (Name) nursing supervisor called. Contact made with (name of ALF) who stated the administrator (name) had left for the day. They also stated that the facility had no available beds at present. (Nursing Supervisor name) spoke with (name) case manager. Phone contact made with (name) at Disability Rights who was aware of the situation and that pt's guardian was on her way to the ER at Hospital B with pt. She also requested the number for the case manager and it was provided."

Review of a progress note dated 05/26/2011 at 1700 by UC #1 revealed "After pt was discharged & we found out (name of ALF) would not accept him (Patient #3) I tried several times to call (name of case manager) on his cell phone & he would not answer. When (name of nursing supervisor) tried to call (name of case manager) from his cell phone he picked up & would not give clear answers. (Name of nursing supervisor) also called (name of ALF) & they did not have knowledge of the pt. A staff person told (name of nursing supervisor) they did not have any beds & the administrator....who (name of case manager) said he talked with was not in. We did not hear back from (name of ALF)."

Review of a "Aftercare Plan" dated 05/26/2011 at 1345 by UC #1 revealed a discharge date and time of 05/26/2011 at 1345. Review revealed the patient was discharged into the care of "Sheriff (to facility)." Review revealed "...Living Arrangements: (check mark in box next to facility)...Relative/Facility/Service: (name of ALF hand written on line)..." Further review revealed the address and telephone number of the ALF. Further review of the Aftercare Plan form and medical record failed to reveal any available documentation Hospital A's discharge planning staff confirmed the acceptance or bed availability at the ALF for Patient #3 prior to his discharge from the hospital on 05/26/2011.

Interview on 06/08/2011 at 1124 with UC #1 and UC #2 (concurrently) revealed they were the unit counselors (UCs) that coordinated the aftercare/discharge plan for Patient #3 during his hospitalization from 04/13/2011 to 05/26/2011. Interview revealed the patient was transferred from an acute care hospital and had resided in an ALF and group home prior to his hospitalization. Interview revealed UC #1 spoke with staff from the patient's previous ALF/group home when performing the patient's psychosocial assessment. Interview revealed the ALF nor group home would accept the patient back upon the patient's discharge. Interview revealed the patient was not an appropriate discharge to home. Interview revealed new placement would be needed upon the patient's discharge. Interview revealed the patient was a difficult placement. Interview revealed the patient was admitted to the hospital's therapeutic lifestyle changes (TLC) unit. Interview revealed the TLC unit works with patient's who have specific mental health and developmental disability issues. Interview revealed Patient #3 was an "active consumer" and had a case manager with a "private community case management agency" (Local Management Entity - LME). Interview revealed the hospital is required to work through the LME for placement and funding. Interview revealed the case manager was not an employee of the hospital. Interview revealed the case manager was not contracted by the hospital to provide discharge planning services. Interview revealed the UCs work in collaboration with the LME case managers. Further interview revealed "the hospital is ultimately responsible for placement of the patient." Interview revealed the UCs had frequent contact with the patient's legal guardian and the patient's case manager. Interview revealed the guardian was in contact with the hospital and case manager. Interview revealed the case manager was attempting to find placement for the patient upon discharge. Interview revealed the guardian and case manager advised the UCs of the patient's acceptance at XXX (state neuro-medical treatment facility). Interview revealed the UCs were advised the placement at XXX may take several weeks and therefore the case manager was searching for temporary respite (placement) in an ALF or group home until XXX confirmed an admission date. Interview revealed the UCs had no communication with XXX to confirm acceptance. Interview revealed the UCs relied on the guardian and case manager to notify the hospital of placement, changes, and updates. Interview revealed the case manager made arrangements at (name of ALF) and then notified the hospital. Interview revealed once the case manager notified the hospital, UC #1 completed the FL-2 and obtained copies of the H&P and TB test results and faxed them to the ALF. Interview revealed the UCs did not have any communication via phone with the accepting ALF to confirm acceptance or bed availability. Interview revealed upon notification by the case manager of the placement, "it did not connect" that the ALF was the same ALF the patient had resided at prior to hospitalization and was not allowed to return. Interview revealed the UCs routinely did not contact the placement facilities arranged by the non-hospital case managers to confirm acceptance or bed availability on the TLC unit. Interview revealed "we trusted the case manager for placement." Interview revealed the patient was discharged in the care of the Sheriff department on 05/26/2011. Interview revealed the hospital was made aware of the ALF's refusal to accept the patient after-the-fact when the Sheriff Department contacted the hospital and advised them of the ALF's refusal to accept. Interview revealed the patient did not return to Hospital A. Interview revealed they were notified the patient was taken to the emergency department at Hospital B by the patient's guardian. Interview confirmed the accuracy of the documentation in the medical record. Interview confirmed the hospital's discharge planning staff failed to ensure the acceptance and bed availability of an assisted living facility prior to the discharge of Patient #3 on 05/26/2011.

NC00073220