HospitalInspections.org

Based on record review and interview the facility failed to provide an appropriate transfer to a facility for 1 of 5 sampled patients (#1).

Findings:

Review of the level II determination summary report for patient #1 reveals the following summary: "the patient was determined to be not appropriate for a nursing facility placement on 10/8/2010 due to irritability, aggression, and unstable mental status. [Patient #1] was discharged from the hospital to a nursing facility and continues to present with maladaptive behaviors and cannot be redirected by staff. [Patient #1] continues to be inappropriate for nursing facility placement and requires further mental health treatment to stabilize [the patient ' s] mental status."

Review of the Case Management notes for patient #1 reveals that the case manager documented on 98/2010 that the patient "will need a PASRR level II for placement in a SNF (skilled nursing facility)."

Review of the medical record for patient #1 reveals that the patient was discharged to a skilled nursing facility on 10/6/2010.

During interview with the social services lead coordinator on 1/4/2011 at 11:30 AM she stated that the Case Manager who completed the discharge planning for patient #1 is no longer at the hospital. She also stated that a level II evaluation should have been completed and a copy should be in the record.