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Based on interview and review of medical records, it was determined that the hospital failed to assure that all necessary medical information was included during the transfer of Patient #1. The hospital's failure to do so resulted in Patient #1 being transferred to an out-of-state rehabilitation facility, with incomplete coordination relative to nursing care needs to both transferring personnel and the receiving facility.

Findings include:

On 1/24/2017, (Registered Nurse) RN #1, who was identified as the primary RN for Patient #1 on the day of the patient's discharge. The RN stated that her/his role in discharges was to "make sure there's a safe discharge and give a good report to transport".

RN #1 confirmed that Patient #1 was discharged to an out-of-state facility, via an air ambulance. The RN confirmed that the air transport was anticipated to take approximately 6 hours.

The RN confirmed that no plan had been developed for how Patient #1, a patient with a history of unpredictable, violent behavior, would have her/his restraints released for range of motion and position changes; how the patient would eat, or how the patient's bowel and bladder needs would be met over the transport period of 6 hours.

The RN stated that s/he had not contacted the facility to which Patient #1 was discharged, to discuss the patient's nursing care needs, because the social worker/discharge planner had told the RN that s/he, the social worker, would give report to the facility. The RN confirmed that s/he did not report to the social worker/discharge planning staff, but reported to the care unit's Nurse Manager.

The Senior Director of Quality & Medical Staff Services stated that the hospital did not have a policy and procedure (P&P) for discharge planning that was specific to rehabilitation facilities, and the P&P for skilled nursing facilities had been implemented.

Review of the hospital's P&P "Discharge Planning Referrals and Documentation of Discharge Plan" was reviewed and found to contain the following directions:
"F. Care Collaboration Model
An integral part of discharge planning is care collaboration between the attending physician or ARNP, the discharge planning staff and other ancillary team members such as nursing and therapists..."

The "Standard Work job aide" for discharge planning for Skilled Nursing Facility was also reviewed and found to contain primarily tasks related to completing computer entries.
"Execution steps" number 10.b. Confirm accepting SNF: confirm RN# for report: Place on Sticky within EPIC".

The hospital's policy and procedure and the job aide did not include directions or prompts to involve the nursing staff in the assessment and planning regarding the patient's status at the time of discharge, or the patient's nursing needs while in transport or at the arrival of the receiving facility.