HospitalInspections.org

Based on document review, medical record review, and interview the hospital failed to ensure (1) of three (3) (Patient #1) discharged patients reviewed were transported to the appropriate after care facility when Patient #1 was transported to a skilled nursing facility (SNF) in another state located 297 miles from the intended SNF that was located in Tennessee. Hospital staff failed to verify the address, city, state, and zip code of the Skilled Nursing Facility (SNF) prior to discharging the patient.

The findings included:

1. Review of the hospital's document titled, "Screen & Assessment Documentation Standards - Transition Management Office" revealed "...Purpose: To define the expectations and requirements for documentation by Transition Management Office (TMO) Case Managers (CM), Social Workers (SW), and Discharge Planners (DP)...Documentation in the medical record of the assessments, interventions, and referrals made by TMO staff is vital to other members of the healthcare team for planning and continuity. Documentation is expected to be thorough, accurate, and timely...Final case management documentation should include the discharge date and destination with the confirmed level of care, contact information, address, and mode of transportation and pick up time...Discharge Planners will receive requests sent to Aidin [an electronic system] as tasks...Final note should include discharge destination with confirmed level of care, contact information, address, and mode of transportation (if arrangements made by discharge planner).

2. Medical record review revealed Patient #1 was admitted to the facility on 3/31/2021 for a scheduled surgical procedure to address a Cervical Disc Disorder with Myelopathy of the Mid-cervical region following an extended period of progressive weakness and contractures in his upper extremity. Patient #1 had urinary incontinence requiring the use of an indwelling urinary catheter and an unsteady gait. The patient's medical history was significant for Diabetes, Coronary Artery Disease, Hyperlipidemia, and Hypertension.

Review of the Operative Report dated 4/1/2021 revealed Patient #1 underwent fusion with laminectomy of his Cervical (C) spine from C2 - T (thoracic spine) 2 to address his pre-and post-operative diagnoses which included Cervical Spondylosis with Myelopathy, Cervical Stenosis, and Cervical Myelopathy. Patient #1 remained hospitalized where he received physical and occupational therapy services.

A Case Management Reassessment/Progress note dated 4/7/2021 revealed the Case Manager (CM) met with the patient to discuss the ongoing discharge plans for Patient #1 to transfer to a SNF for further rehabilitation services. The CM indicated she was having difficulty finding placement due to the patient's insurance, but was continuing to work to find placement.

A Case Management Reassessment/Progress note dated 4/8/2021 revealed the CM met with the patient and his spouse and informed them a facility had accepted the patient after the referral had been "manually faxed" to the receiving facility. The CM's note listed the name of the facility and a contact phone number. There was no physical address of the facility documented in the note. The note further indicated the patient would be transported to the receiving facility via wheelchair transport van and indicated the Discharge Planning Coordinator would be assisting to set up the transportation.

Review of the nursing flowsheet dated 4/9/2021 revealed Patient #1 was alert and oriented and had discharge vital signs of Blood pressure 169/87, Pulse of 66, Respiratory rate of 16, and an oxygen saturation rate of 99%.

Review of the Discharge Summary dated 4/9/2021 revealed Patient #1 was "...ready for discharge today..."

Review of an ED Provider Note dated 4/9/2021 at 6:52 PM, revealed, Patient #1 "discharged from orthospine today. Unfortunately he was taken to the wrong facility and had to be brought back. Reportedly can go to the appropriate facility in the morning...Orthopedic surgery was consulted for this bounceback. He was re-admitted to their service while he waits for transport again tomorrow..."

Review of an Internal Medicine Consult note dated 4/11/2021 at 9:00 AM revealed, Patient #1 was discharged on 4/9/2021 but was taken to Kentucky instead of Tennessee. The patient was brought back to the hospital and readmitted.

Review of the Discharge Summary dated 4/14/2021 revealed Patient #1 "was again discharged on 4/10/21 after being re-admitted for an improper transfer to the wrong SNF 4/9/21..."

Review of the facility's event summary revealed Patient #1 was transported by mistake to a SNF in Kentucky with the same name as the intended SNF located in Tennessee.

In an interview via teleconference on 5/11/2021 at 11:27 AM, CM #1 verified Patient #1 was transported to a SNF in Kentucky instead of Tennessee. The CM continued and stated the patient went by wheelchair van and the Discharge Planner made the arrangements. CM#1 verified there was no documentation of the address of the SNF, only the name of the facility and a phone number.

In an interview via teleconference on 5/11/21 at 1:24 PM, the Director of Patient Relations stated, "Unfortunately, type of miscommunication and he [Patient #1] was transported to Kentucky instead of Tennessee...it was a mix up with CM and transportation company. He had to be brought back..." When asked how the patient was transported to the wrong location, the Director of Patient Relations stated, "I would assume there was an error somewhere..."

In an interview via teleconference on 5/11/2021 at 2:01 PM, the Vice President (VP) of Transition Management stated the CM failed to follow the facility's standard of practice screening and assessment documentation standards when she failed to include the address, city, state, and zip code of the facility in her documentation. The VP of Transition Management further stated the Discharge Planner was not familiar with the SNF located in Tennessee, but was familiar with a SNF with the same name located in Kentucky so he made arrangements for the patient to be transported to the SNF located in Kentucky instead. The VP of Transition Management continued and stated the transportation company contacted the SNF in Kentucky shortly before they arrived with the patient and was informed the SNF was not expecting the patient. The transportation company then informed the hospital of the event and was instructed to bring Patient #1 back because the other SNF was located over 3 hours away in Tennessee. The VP of Transition Management continued and stated Patient #1 was re-admitted to the facility, and arrangements were made for the patient to be transported to the SNF located in Tennessee. The VP of Transition Management then stated the facility met with their CM team and said the event "would not have happened if we would have had the city and state listed."

In a telephone interview on 5/11/2021 at 4:12 PM, the Department of Transportation Management (DPM) Supervisor informed this surveyor his department was responsible for setting up transportation for patient's being discharged from the hospital. The DPM Supervisor continued and stated his staff members did not always ask for the address of the facility the patients were being transported to if it was a facility they were familiar with. The Supervisor stated they made arrangements for Patient #1 to be transported to a SNF located in Kentucky because they were unaware there was a SNF with the same name located in Tennessee.

In a telephone interview on 5/11/2021 at 4:19 PM, Dispatcher #1 informed this surveyor Patient #1 was transported by their van driver to a SNF in Kentucky and was informed by the SNF that they were not expecting any new patients. The Dispatcher continued and stated the van driver called her and she called the DPM Supervisor who discovered the patient should have been taken to the SNF located in Tennessee instead of Kentucky. Dispatcher #1 then stated, "They gave us the wrong address. [DPM Supervisor] asked if we could take him to the TN location...but it was too late. We were told to bring him back..."