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Based on interview and record review the facility failed to ensure the patients representative was informed and approved of the patients discharge plan, prior to being discharged, for one (Patient 1) of 30 sample patients.

This failure resulted in Patient 1 being discharged to a facility without patient representative agreement or notification.

Findings:

On March 20, 2025, an unannounced visit was conducted at the facility for a complaint validation survey.

On March 20, 2025, at 1:30 p.m., Patient 1's medical record was reviewed with the Quality Patient Specialist (QPS).

The facility document titled, "ED Provider Notes" dated February 24, 2025, at 2:04 p.m., indicated Patient 1 came in on February 24, 2025, for constipation. The document further stated, "...Hospice and patient daughters attempting placement...The patient's daughter states she will arrange a place for her mother [Patient 1]..."

The facility document titled, "Multidisciplinary Progress Note," dated February 24, 2025, at 12:59, and authored by Social Worker (SW) 1 was reviewed and indicated, "...1525[3:25 p.m.]: Called second time and left another message for pt's [Patient 1] daughter to call back regarding DCP [Discharge Planning]. SW will continue efforts to find placement for patient. At this time, patient [Patient 1] is not fully (A&O) [alert and oriented] and next of Kin, Tasha (daughter) will need to provide directive on DCP..."

The facility document titled, "Consults" dated February 25, 2025, at 10:59 a.m., and authored by SW1 was reviewed and indicated, "...Summary: Placement...Spoke with pt's daughter this morning and she requested to communicate only with the Director. She was transferred to the CM[Case Management]/SW Director...ED [Emergency department] Physician and RN [Registered Nurse] notified and will prepare pt for discharge..."

The facility document titled, "Multidisciplinary Progress Notes" dated February 25, 2025, at 1:07 p.m., was reviewed and indicated, "Received call from Stephanie R&B [Room and Board]...that patient is going to Joy's Room and Board...SW 3 way called with Joy and Stephanie. Joy is aware and will be expecting the patient soon..."

The facility document titled, "ED Notes," dated February 25, 2025, at 12:41 p.m., was reviewed and indicated, "[Name of local transport] contacted to transport the patient... ETA [Estimated Time Arrival] 1320[1:20 p.m.] - 1340 [1:40 p.m.]..."

The facility document titled, "ED Notes" dated February 25, 2025, at 1:24 p.m. was reviewed and indicted, "...Pt's [Patient 1] daughter called upset after patient was placed in a new board and care by [Name of SW 1]. She was upset she did not approve this prior to the transfer..."

An interview was conducted on March 21, 2025, at 8:30 a.m., with SW 1. SW 1 stated he called the pt's [Patient 1] daughter and left a voicemail. He stated she refused to talk to him and only wanted to talk with the supervisor. He stated he received a call from Stephanie from the R&B stating the patient [Patient 1] was going to go to her sister's R&B. He further stated he had a three way call with Stephanie and Joy to make arrangements for Patient 1's transport. He further stated he never spoke with, informed, or received approval from Patient 1's daughter for the transfer. SW 1 further stated he should have spoken to Patient 1's daughter prior to her being transferred.

An interview was conducted on March 21, 2025, at 8:45 a.m., with the Director of Case Management (DCM). The DCM stated she recalled Patient 1's daughter not wanting to speak with SW 1 an requested to speak with his supervisor. She stated she was able to reach Patient 1's daughter on the telephone. The DCM further stated, she did not inform or receive approval from Patient 1's daughter for Patient 1 to be transferred to any facility. The DCM further stated SW 1 should have informed Patient 1's daughter of the placement and gotten approval prior to Patient 1 being discharged.

A review of the facility policy titled, "Clinical Management" revised August 2021, was conducted and indicated, "...The patient, family, and/or significant others shall be included in the planning process, and shall be informed, orally or in writing..."

A review of the facility policy titled, "Patient's Rights", revised March 2021, was conducted and indicated, "...Be informed by the physician, or delegate of the physician, of continuing health care requirements and options following discharge from the hospital. The patient has the right to be involved in the development and implementation of the discharge plan. Upon the patient's request, a friend or family member may be provided this information also..."

A review of the facility policy titled, Case Management" revised August 2021, was conducted and indicated, "...Discharge planning services are provided to patients with the involvement of an interdisciplinary team including the patient, the patient's family/significant other, licensed medical provider and staff involved in the patient's care, treatment and services to appropriately deal with the impact of illness..."