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Based on interview, record review, and review of the facility's policies it was determined the facility failed to ensure one (1) of ten (10) sampled patients was transferred, along with necessary medical information, as needed, for follow-up care. Patient #4 was transferred to another facility without a medication list or follow-up laboratory test instructions. In addition, no nursing documentation related to the patient's condition at discharge or final disposition was present.

The findings include:

Review of the policy titled "Transfer of Patients", effective 10/2008, revealed the primary attending physician or designee "will notify the unit clerk to copy record or discharge summary to the psychiatric hospital".

Review of the policy titled "Discharges-Hospital Inpatient", effective 07/2008, revealed discharge planning is implemented to "achieve a smooth transition to the next level of care, including continuity of care and other identified needs".

Review of the clinical record revealed the facility admitted Patient #4 on 04/17/11 with diagnoses which included Multiple Facial Fractures secondary to a self-inflicted gunshot wound. In addition the patient had a history of Seizures and Deep Vein Thrombosis (blood clots). Continued review revealed the patient required chronic anticoagulation therapy (to prevent the formation of new blood clots).

Review of the Discharge Summary, dictated 04/22/11, revealed Patient #4 was to be discharged to the receiving facility under a mental health petition. Further review revealed the patient's discharge instructions included medications to treat infection and pain, and to prevent seizures and blood clots. In addition, the patient was to have his/her blood clotting time checked the following day, due to the patient's medical history and the use of anticoagulant therapy during the hospital stay.

Review of the "Patient Home Medications to Continue" section of the hospital Discharge Orders revealed a hand-written note to "see dictation". Continued review of the "X-Ray/Labs Needed" section revealed no instructions or reference to the need for a laboratory test to check the patient's blood clotting time.

Review of nursing documentation for 11/22/11 revealed no notation related to the patient's transfer.

Review of the closed record at the receiving facility revealed the Discharge Orders form was included. However, no copy of the Discharge Summary, i.e. the dictation referenced on the form, was not present.

Review of the evaluating physician's note at the receiving hospital revealed the resident arrived with no medication orders. Continued review revealed the patient did not meet admission criteria at the receiving hospital and was discharged to home. Further review revealed the patient was discharged to home without medications or instructions for laboratory testing.

During interview, on 11/11/11 at 9:40 AM, Registered Nurse (RN) #1 confirmed there was no nursing documentation related to the transfer disposition of Patient #4. She stated she would have expected to see a notation of the event.

Interview with the Director of the Triage Center at the receiving facility, on 11/14/11 at 3:35 PM, revealed Patient #4 did not have the transferring physician's Discharge Summary on arrival. The Director stated the patient did not have any medication orders or instructions for laboratory testing.

Interview with the Director of Social Services for Medical-Surgical patients, on 11/17/11 at 12:50 PM, revealed when a patient was transferred to another facility, including the receiving facility in this instance, the following documents should accompany the patient: an inter-facility transfer form, the Discharge Summary, the Medication Administration Record for the day of the transfer, and any psychiatric consultation notes. She stated the social worker would normally copy the psychiatric notes and place them with the discharge paperwork. However, she continued, Patient #4 was transferred after hours, and no hospital social worker was involved in the transfer.

Interview with RN #2, on 11/17/11 at 12:55 PM, revealed the nurse on the unit should have completed a "Discharge Form" before the patient left the facility. She stated the form contained basic information, including the patient's condition, and how the patient was transferred and with whom. She further stated the form became a part of the permanent Medical Record. Continued interview revealed RN #2 had looked for the form in Patient #4's record, but "it just wasn't there".

Interview with the Patient Care Manager for the unit where Patient #4 was located revealed she had reviewed the record and could not find any nursing documentation related to the patient's transfer. Continued interview revealed it was unclear who the transferring nurse was. Therefore, the nurse could not be interviewed.

Interview with the Interim Director for Accreditation and Regulatory Compliance, on 11/17/11 at 1:00 PM, confirmed there was no evidence in the patient's record that an inter-facility transfer form had been completed by the nurse. She also confirmed there was no nursing documentation related to the patient's condition or intended disposition upon transfer. She stated there was no current policy that addressed what documents should accompany a patient on discharge from the hospital. She stated she would, however, expect to see some documentation in the record regarding the patient's discharge. She could not say why the physician's Discharge Summary, which included the patient's home medications and follow-up laboratory orders, was not sent with the patient upon transfer to the receiving facility.