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Based on record review, and staff interview, and document review, it was determined that the facility failed to ensure compliance with transfer arrangements or refer of patients, to an appropriate facility for 1 ( #3) of 4 patients reviewed on the survey sample. This practice could potentially result in an adverse outcome for the patient.

Finding Include:


1. Patient #3 was admitted to the facility on 7/25/10 for a planned Right Total Hip Replacement per the facesheet. A total right hip replacement procedure was conducted on 7/26/10 with no complications identified per the medical record. The case manager's initial discharge planning assessment documented that the patient lived alone, independent with Activities of Daily Living, and ambulated with a cane patient #3 was identified as a high risk discharge for impaired safety. The patient's mental status/cognition was alert and oriented, with identified teaching needed for safety precautions. The case manager report, dated 7/28/10, documented discussed with patient the need for rehab. The patient was agreeable to a local rehab facility (SNF#1). The case manager stated the local rehab facility accepted the patient and the discharge date was 7/29/10. However; the case manager on 7/29/10 talked with the patient about the discharge. Patient# 3 stated s/he changed their mind because he/she did not want to pay for transportation from the local rehab facility and transportation to his/her home in a different area. The case manager stated she talked to patient #3 about local facilities near where the patient# 3 lived. The patient# 3 decided on a nursing home,but was not accepted due to an insurance issue. The patient then picked another facility(SNF#3). According to the case manager s/he stated that, on 7/29/10, he/she called the nurse on the 5th floor and stated do not discharge the patient #3 today. The case manager stated to surveyor he/she was working trying to obtain placement for another facility. The nurse who discharged patient #3 on 7/29/10 was interviewed on 8/10/10 at 1:40 p.m. and stated to surveyor the patient stated he/she wanted to go to a facility closer to home, and that case manager was working on that. The nurse stated later in the afternoon on 7/29/10 the patient stated he/she spoke with the case manager and stated everything was a set for discharge. The nurse stated the paperwork for discharge was in an envelope, but did not open the envelope to check the contents. The nurse additionally, stated he/she did not recall the case manager calling. The patient #3 was discharged. According to the nurse's interview he/she stated the patient gave the transport driver the wrong address of the facility the case manager was still working on for placement. The SNF #3 did not accept the patient due to the facility not going through proper channels per the hospital case manager during interview on 8/10/10 at 12:15p.m.. patient #3 was transport back to the facility. The case manager called the facility (SNF#3) and they stated they did not want to get involved with patient #3. The case manager called another facility SNF#2) per patient agreement and the patient was accepted. The patient was discharged on 7/30/10 to SNF#2. However; the Medical Certification for Nursing Facility/Home and Community Based Services form (3008) was reviewed and the receiving facility (SNF#1) name was crossed out and no other name was identified where the patient was being transferred too, and the physician had signed and dated the 3008 for the SNF#1 discharge. The review of the discharge planning policy and procedure documented the planning for transfer or discharge involves the patient and all appropriate health care providers, staff, and family members involved in patient's care, treatment and services. There was documented evidence that there was a breakdown in communication by the case manger and nursing staff and patient by not following facility policy for discharge planning.