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Based on record review and interview, the facility failed to ensure an appropriate discharge planning include the availability of services to meet the identified needs following hospitalization for 1(SP#1) of 10 Sampled Patients.

The findings Include:
Record review showed that SP#1 was admitted from an ALF#1(Assisted Living Facility) to the facility via emergency room on 10/10/2014 because of gross hematuria. He was found to have pneumonia, and Urinary Tract Infection (UTI). Patient had a history that included: metastatic prostate, bladder, and renal cancer, coronary artery disease, dementia, and hypertension. The patient was generally weak. The plan was to transfer patient back to the ALF#1 under the care of Hospice.
Record review of SP#1 Case Management report showed that Hospice was called on 10/12/14 upon request for evaluation. On 10/17/14 family signed consent for hospice and the ALF#1 was notified. Case Management was informed by the ALF#1 that SP#1 will not be accepted back to the ALF#1.
Review of the Discharge assessment on 10/17/14 showed SP#1 was disoriented, bed bound, incontinent, and unable to reposition self in bed. Skin assessment showed eschar wound on the sacral area, and stage II on the left hip. Patient was discharged via ambulance on 10/17/2014 to ALF#2 with discharge instructions under Hospice care.
SP#1 medical record showed no evidence that patient was officially under Hospice care at the time of discharge.
Interview with the Risk Manager on 12/03/14 around 2 PM revealed that the family of SP#1 wanted the patient to go back to the original ALF#1 but the ALF#1 refused to take the patient back, and that their understanding was that patient can stay in an ALF as long as the patient was under hospice care. Risk Manager also stated that they will take this opportunity to educate the nursing and case management about criteria and limitation for hospice care in the ALF. The hospital normally discharges the patient under hospice services even when patient continue to stay for a few days. Hospice takes over the care and manage patient under their services.