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Based on interview and record review the facility failed to reassess 1 (SP#1) of 4 sample patients (SP) discharge plan for the appropriateness of the discharge plan.

Findings include:


Review of sample patient (SP) #1 Discharge Summary dated 03/24/2019 at 7:11 PM revealed the date of admission: 03/19/2019. The discharge date: 03/24/2019.

Record review showed on 03/24/2019, Patient (SP #1) was discharged back to the Assisted Living Facility today due to transportation issues the previous night. Discharge medications prescribed for deep vein thrombosis prophylaxis, seizure disorder, cholesterol, blood pressure and infection. Discharge instructions for dressing of low extremities with thera-honey, kerlix and ace bandage daily and follow-up appointment with neurology in 1-2 weeks.

Record review showed on 03/24/2019 at 10:00 AM documented that the transport came to pick up (SP #1) patient by 11:00 PM and since patient was going to an ALF, the discharge had to be held because there was no receiving staff at the location. Case Manager called ALF and talked to the owner whom agreed to take the patient back. Transportation by 11:00 AM, the nurse and the patient were made aware.

Record review showed on 03/24/2019 at 12:15 PM documented order for home health. Case Management talked to (SP #1) patient and sent referrals to home care agency as per insurance regulations. The transportation arrived to pick up the patient. Talked to the owner of the ALF who wanted physical therapy, registered nurse, shower chair and a raised toilet seat. Case management got the order and send to the home health agency.

Record review 03/24/2019 at 12:16 PM documented that the medications for the (SP #1) patient will be picked up per the owner of the ALF who will also make sure that the patient takes the anticonvulsant regularly.

Review of SP#1 Order Record dated 03/23/2019 at 2:24 PM documented new response set entered at 10:51AM for Disposition - Assisted Living Facility (ALF), Home Health Dressing Change and at 12:11 PM for please provide a shower chair and a raise toilet set for this patient at the ALF.

Interview with Vice President of Quality on 06/12/2019 at12:46 PM revealed that SP #1 was discharged to an Independent Living Facility.

Facility did not verify licensure of the discharge location.


Interview with Case Management Director on 06/10/2019 at 12:35 PM revealed The Agency for Health Care Administration (AHCA) facility locator is used for discharge placement. The information from the AHCA website is copied and pasted in the case manager notes to verify the facility is licensed.

Interview with Staff-B on 06/10/2019 at 12:55 PM revealed if a patient was admitted from an ALF and had experienced too much decline during the hospital stay, the patient will not be able to return to the ALF. If the physician has ordered discharge to ALF, the ALF is verified through the Agency for Health Care Administration (AHCA) website. The provider's license is printed, and contact is made with the facility's administrator or director of nursing. Recalls SP#1 and states patient was awake, alert and oriented times three and choice was to go back to the ALF. Did not copy and paste the licensure verification on the case management notes.