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Based on document review and interview, the facility failed to follow established policy for discharge planning for 6 of 10 medical records reviewed (Patient's 2, 3, 4, 6, 8 and 10).

Findings Include:

1. Review of policy titled: Discharge Planning last approved 01/2016 indicates that the Case Manager is responsible for verifying the physician agrees, provides appropriate referral lists to family, ensure family agreement with plan, verifying insurance, communicate with receiving facility, arrange transportation and DME if needed and provide the telephone number for the bedside nurse to call the receiving facility to discuss the patient's condition and care needs utilizing SBAR (Situation, Background, Assessment and Recommendation) communication.

2. Review of medical records (MR) for Patient's 2, 3, 4, 6, 8 and 10 lacked documentation of communication of facility nurse to receiving nurse communication utilizing the SBAR communication process.
a. Patient 2 was discharged on 05/03/18 to a skilled nursing facility and the MR lacked documentation of a facility nurse communicating to receiving facility nursing staff.
b. Patient 3 was discharged on 05/04/18 to rehabilitation facility and the MR lacked documentation of a a facility nurse communicating to receiving facility nursing staff.
c. Patient 4 was discharged on 05/10/18 to skilled nursing facility and the MR lacked documentation of a facility nurse communicating to receiving facility nursing staff.
d. Patient 6 was discharged on 05/31/18 to skilled nursing facility and the MR lacked documentation of a facility nurse communicating to receiving facility nursing staff.
e. Patient 8 was discharged on 04/05/18 to skilled nursing facility and the MR lacked documentation of a facility nurse communicating to receiving facility nursing staff.
f. Patient 10 was discharged on 04/09/18 to skilled nursing facility and the MR lacked documentation of a facility nurse communicating to receiving facility nursing staff.
Unable to verify facility nursing staff communicated with receiving facility nursing staff of the patient's condition and care needs utilizing SBAR (Situation, Background, Assessment and Recommendation) communication.

3. Interview with P51, Director of Quality on 08/13/18 at 3:00 pm confirmed lack of documentation of facility nurse communicating with receiving nurse in a transfer in Patient's 2, 3, 4, 6, 8 and 10. Indicated documentation of communication is not necessary as it is a Standard of Practice that is educated with Registered Nurses in orientation.