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Based on record review and interview, the facility failed to ensure that for one of one patients (patient #1) physical rehabilitation/physical therapy was obtained and/or documentation as to why Patient #1 was unable to receive the physical rehabilitation/physical therapy was available in her medical record.

Findings included:

Record review on 05/05/15 of Patient #1's Discharge Orders Inpatient, dated 02/02/15 at 1345 PM, revealed but was not limited to the following: " Discharge Disposition: Physical rehabilitation/Physical Therapy. Medical Follow up (specify reason): Physical rehabilitation care for deconditioning syndrome. Discharge Diagnoses: Axis II: Deconditioning syndrome; decubiti ulcer.

Record review on 05/05/15 of Patient #1's Discharge Evaluations and Summaries, dated 02/03/15 at 1545 PM, revealed but was not limited to the following: " Continued Care Goals and Followup Appointment: Behavioral Health Care on 02/04/15 and ______ Community Health Center on 02/05/15.

Record review of Patient #1's Discharge Summary, completed by the psychiatrist and dated 02/03/15, revealed but was not limited to the following: " Our evaluation found no evidence of any ongoing depression symptoms. She was accordingly discharged with her primary concern that she had developed a deconditioining syndrome due to her prolonged recumbent posture in bed and in her muscles were weak and her posture was poor. We attempted to discharge her to a physical rehabilitation unit, but that was not feasible. We consequently made arrangements to have her be discharged to the home of a cousin, other relative, or a friend and arrange for home healthcare services to provide physical rehabilitation and physical therapy services."

Review on 05/06/15 of _____ Community Health Center web site (www.amistadchc.com/id10.html) revealed this agency did not provide home health services and/or physical therapy services.

Interview on 05/06/15 at 10:00 AM with Facility Discharge Planner #1 revealed that Patient #1 was "unfunded so the discharge orders for physical rehabilitation/physical therapy/home healthcare services could not be implemented". She confirmed that the community health center that Patient #1 was referred to did not provide these services. She stated that due to time contraints she was unable to document every interaction regarding discharge planning.

Interview on 05/06/15 at 10:30 AM with Facility Therapist #1 revealed Patient #1 was "unfunded and therefore the facility was unable to refer her for the ordered services. He stated the psychiatrist had believed that she might be eligible for home healthcare services through a mental health home health care agency but because she did not have any current symptoms of mental illness, she was not eligible for their services".

Interview on 05/05/15 at 4:00 PM with Patient #1's Case Manager #1 revealed that on 02/04/15, Patient #1 called him from her friend's house needing assistance. He went to Patient#1's friend's house. He stated Patient #1 was "in excruciating pain and appeared disheveled and dirty". She was "unable to walk and had to crawl to the bathroom the night before". She showed Case Manager #1 her "bedsore" which appeared reddened and inflamed". He called an ambulance and she was admitted into an acute care hospital. He indicated she remained in this acute care hospital approximately one month.