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Based on record review and interview, the facility failed to ensure that discharge planning has the consent of the resident and/or legal representative for 1 of 5 (#2) patients' records reviewed.

The findings include:

Review of patient #2's record revealed the patient was admitted on 01/05/2012. A discharge note dated 01/12/12012 indicated that the patient will need a week of rehabilitation upon discharge from the facility, in a Skilled Nursing Facility (SNF). A SNF faxed note dated 01/11/12 indicates that the SNF would accept patient #2 and the hospital notified a Home Health Care Agency on 01/13/2012 of additional services the patient would require post-discharge.

Review of a Case Management (CM) note dated 01/13/12 that the CM had a discussion with patient #2's family member and the family member was concerned about patient #2's functional ability due to her recent confusion. Another CM note dated 01/12/12 states that the CM visited patient #2 in her room and she did not appear to be ready for discharge. A note dated 01/31/12 states that the patient was assessed by physical therapy for SNF placement. Another note also date 01/31/12 revealed that the same SNF that accepted patient #2 on 01/11/12 was notified about the patient's discharge and acceptance into the SNF. On 02/01/12 another note states that patient #2 was sent via a transport company to the SNF for admissions and was discharged from the hospital. There is no documentation that patient #2's Health Care Surrogate/Durable Power of Attorney was notified that the patient was being discharged to a SNF on 02/01/12.

Review of the facility's incident/accident log revealed a report filed by patient #'2's Health Care Surrogate/Durable Power of Attorney regarding not being notified about patient #2's impending discharge.

Review of the facility's policy titled, "GLOBAL- Discharge Planning", with review date of 8/28/2008 revealed, "It is a coordinated process by which health care professionals, patients, and families collaborate to insure that patients have access to services that enable them to regain, maintain and increase the level of functioning achieved in the hospital." Further review of the policy and procedure revealed, "Each health care professional involved in the patient's care is responsible for medical record documentation of the care provided in preparation for discharge including patient/family teaching, review of the discharge instructions, review of the discharge alternatives presented to the patient/family, referrals made to community agencies for services post-discharge , and changes in the discharge plan due to changes in the patient's medical condition or psycho-social situations."

Interview with the Case Manager on 02/29/12 at 2:30 PM revealed that the facility's CMs are unit based and make rounds daily and discuses information with clinical staff daily. Further interview revealed the nursing initially makes the patient specific data input and triggers a task to the CM group. Patients and families can ask for a discharge planning review. If the patient is confused, the CMs will involve the family in the discharge planning and they always get the Health Care Surrogate and Durable Power of Attorney involved in the discharge planning. According to the Case Manager, "I remember [patient #2] and the daughter did not get called prior to the patient being discharged.

Interview conducted with patient #2's daughter at 6:00 PM revealed that when she went to visit her mother and found her hospital room empty and saw the bed had been stripped, she "panicked." According to the family member, she thought, "Mom had died".