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Based on record review and interview, the facility failed to reassess the patient's discharge plan prior to transfer to an inappropriate facility after discharge in one (Sampled Patient #1) of ten sampled patients.

The findings:

Review of the facility's policy titled,"Discharge Planning Process," dated 2014, state the discharge planning process provides monitoring to ensure the patient will received needed care in a timely fashion from the appropriate provider in the appropriate level or setting or care.

Sampled patient #1 medical record showed that the patient arrived to the hospital on 11/19/14. On 11/18/14 the "Resident Transfer Form" from the skilled nursing facility [SNF]) (Facility #3) showed that the patient was being transferred to the hospital for altered mental status, wandering, schizophrenia chronic paranoid type. The Emergency Room (ER) Triage notes on 11/19/14 at 11:26 PM stated that the patient was confused and a poor historian. On 11/19/14 at 2:12 PM, the patient was admitted to the facility. The nursing admission assessment on 11/19/14 at 2:21 AM showed that the patient was disabled. In the case manager initial assessment on 11/21/14 at 8:53 AM, it stated that sampled patient #1 came from the skilled nursing Facility #3 and per [name of person] from admissions the patient is not accepted back at the facility, and another skilled nursing facility.

The assessment also showed that the patient was considered for skilled nursing services in preparation for discharge. The case manager notes further state on 11/21/14 at 3:10 PM that the case manager will find placement and that patient will be referred to facilities as per list.

The Physician Progress notes on 11/25/15 at 8:31 AM then showed that the patient's discharge disposition was to a skilled nursing facility. The case manager discharge disposition report on 11/27/14 at 9:29 AM showed that the patient was discharged to an Assisted Living Facility (ALF).

Review of SP#1 next admission record showed that the patient returned to the facility on 11/26/14 at 4:01 PM, from the ALF. The triage notes on 11/26/14 at 4:29 PM then stated that he was confused and continuously wandering and not following commands. The ER physician notes on 11/26/14 at 5:07 PM also stated, that he was confused, and that he was discharged from the Psych Unit today to an ALF, now this ALF sent the patient back to our ER stating we cannot take care of this patient. The notes showed that the patient's mental status was unable to be assessed. The case manager notes on 11/27/14 at 11:01 AM stated that the patient was accepted in a Independent Living facility. The patient was then transported by Hospital transportation to the Independent Living facility.

Further review of the case manager notes dated 12/30/2014, showed that a call was received from the patient ' s wife reporting that she was not able to contact her husband. The note then state that the case manager reviewed the notes and the patient was discharged to [name] ALF. The next case manager notes dated 12/30/2014 on 18:58 PM, then report that a second call received from the wife who stated that she called the [same named ALF] and spoke with [named] who stated that he had never received that patient.

On 03/02/15 at 2:11 PM, Staff E, a case manager, stated that she saw the patient in the ER when the patient returned from the ALF. She then stated that she called the Administrator at the independent living facility, and he accepted the patient. She stated that the patient was alert and was able to make decisions.


On 03/03/15 at 1:10 PM, the Revenue Cycle Director confirmed that the [named facility] was an independent living facility. She stated that patients in an independent living facility can come and go out of the facility freely. She stated that there is no staff caring for patients who live in an independent living facility.

On 03/02/15 at 11:34AM, Staff A, Case Manager stated that when patients arrive to the facility, the case manager verifies where the patient came from by calling that facility. She stated that sometimes patients return to the facility from which they came. However, sometimes, that facility will not accept them back. She stated that if a nursing home will not accept a patient back, she would contact the doctor and the patient ' s family to inform them and then start the referral process. She stated that if the patient will be transferred to an ALF or nursing home, a list of providers would be given to the patient. The patient would then select the discharge location. She stated that if a patient was not coherent, the family would be contacted to select the discharge location.


On 03/02/15 at 1:06 PM, Staff B, Case Manager, stated that the patient and family make decision for final discharge disposition.

Based on record review and interview, the facility failed to ensure the patient were transferred to the appropriate facility after discharge in one (Sampled Patient #1) of ten sampled patients.

The findings:

Review of the facility's policy titled,"Discharge Planning Process," dated 2014, state the discharge planning process provides monitoring to ensure the patient will received needed care in a timely fashion from the appropriate provider in the appropriate level or setting or care.

Sampled patient #1 medical record showed that the patient arrived to the hospital on 11/19/14. On 11/18/14 the "Resident Transfer Form" from the skilled nursing facility [SNF]) (Facility #3) showed that the patient was being transferred to the hospital for altered mental status, wandering, schizophrenia chronic paranoid type. The Emergency Room (ER) Triage notes on 11/19/14 at 11:26 PM stated that the patient was confused and a poor historian. On 11/19/14 at 2:12 PM, the patient was admitted to the facility. The nursing admission assessment on 11/19/14 at 2:21 AM showed that the patient was disabled. In the case manager initial assessment on 11/21/14 at 8:53 AM, it stated that sampled patient #1 came from the skilled nursing Facility #3 and per [name of person] from admissions the patient is not accepted back at the facility, and another skilled nursing facility.

The assessment also showed that the patient was considered for skilled nursing services in preparation for discharge. The case manager notes further state on 11/21/14 at 3:10 PM that the case manager will find placement and that patient will be referred to facilities as per list.

The Physician Progress notes on 11/25/15 at 8:31 AM then showed that the patient's discharge disposition was to a skilled nursing facility. The case manager discharge disposition report on 11/27/14 at 9:29 AM showed that the patient was discharged to an Assisted Living Facility (ALF).

Review of SP#1 next admission record showed that the patient returned to the facility on 11/26/14 at 4:01 PM, from the ALF. The triage notes on 11/26/14 at 4:29 PM then stated that he was confused and continuously wandering and not following commands. The ER physician notes on 11/26/14 at 5:07 PM also stated, that he was confused, and that he was discharged from the Psych Unit today to an ALF, now this ALF sent the patient back to our ER stating we cannot take care of this patient. The notes showed that the patient's mental status was unable to be assessed. The case manager notes on 11/27/14 at 11:01 AM stated that the patient was accepted in a Independent Living facility. The patient was then transported by Hospital transportation to the Independent Living facility.

Further review of the case manager notes dated 12/30/2014, showed that a call was received from the patient ' s wife reporting that she was not able to contact her husband. The note then state that the case manager reviewed the notes and the patient was discharged to [name] ALF. The next case manager notes dated 12/30/2014 on 18:58 PM, then report that a second call received from the wife who stated that she called the [same named ALF] and spoke with [named] who stated that he had never received that patient.

On 03/02/15 at 2:11 PM, Staff E, a case manager, stated that she saw the patient in the ER when the patient returned from the ALF. She then stated that she called the Administrator at the independent living facility, and he accepted the patient. She stated that the patient was alert and was able to make decisions.


On 03/03/15 at 1:10 PM, the Revenue Cycle Director confirmed that the [named facility] was an independent living facility. She stated that patients in an independent living facility can come and go out of the facility freely. She stated that there is no staff caring for patients who live in an independent living facility.


On 03/02/15 at 1:06 PM, Staff B, Case Manager, stated that the patient and family make decision for final discharge disposition.