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Based upon record review and interviews, the hospital failed to follow their Discharge Planning Policy that included direct communication with the transportation company to ensure each patient was appropriately transferred to the entity identified in the Discharge Plan. This was evidenced by the review of 1 of 5 (Patient #1) patients Discharge Plans whereby the patient was transferred to her former residence instead of to the designated long term care facility. Findings:

Review of Policy SS 014, Discharge Planning revealed Purpose: F. Include timely and direct communication with the transfer of information to other programs, agencies, or individuals that will be providing continuing care.

Review of patient #1's medical record revealed on 05/02/17, the patient was admitted for Major Depressive Disorder with anxious distress and Neurocognitive disorder and discharged on 05/23/17 to the IOP (Intensive Outpatient Program).

According to the Discharge Summary by S8Psychiatrist "The patient was admitted to PBH for extreme exacerbation of mood and memory issues. The patient safety risk and needs to be medically stylized as well. (S7Physician) was consulted and labs were ordered. The patient had a very fluctuating hospital course, did not know situation she was in, needed redirection in groups and on the unit. She did not have any behavioral outbursts, and as soon as her medications were stabilized, she did not wander and wake up during the night. The patient was behaviorally compliant and had no outbursts or no issues but she was under supervised care 24/7 and this benefited the patient. It was noted the patient's MoCA and MMSE were quite low and family therapy was done to discuss her situation and her safety issues because she stays home all day alone. It was decided that the patient's best needs would be a nursing home placement and the patient did not fully understand that because of her dementia. Her daughter agreed to this and that process was started and completed upon discharge."

On 05/22/17, S3PLPC documented in patient #1's medical record that the patient was accepted to a long term care facility and the information was faxed to the nursing home.

Review of the Daily Nursing Note dated 05/23/17, S9RN(Registered Nurse) documented ""(Patient) presents with anxious mood, blunted effect. She is oriented to person and this morning can tell me that the month is May. She is still forgetful and not oriented to place or situation. She denies having any problems. Medication regime reviewed with her and written copy of same given. Discharged ambulatory to IOP, accompanied by staff at 9:25 a.m. Condition fair."

Interview on 09/27/17 at 1:05 p.m. with S4LPC(Licensed Professional Counselor)/Director of the IOP revealed after patient #1 was discharged from the hospital on 05/23/17, hospital staff brought the patient to the IOP for further outpatient care. S4LPC further stated patient #1 was a former IOP patient and had her own transportation with Transportation A who would bring her to the outpatient facility prior to her hospitalization on 05/02/17. When asked how Transportation A knew where to take the patient after the outpatient therapy, she replied when S5MHT(Mental Health Technician) called the transportation company to pick the patient up from the IOP, he would tell them where the patient was to be transferred to. When asked about patient #1, S4LPC stated the Transportation A company transferred the patient to her former residence instead of to the nursing home where she was to be admitted. S4LPC further added patient #1 was dropped off at the apartment building with her suitcase, was confused, and when she found the apartment door was locked, she roamed around the apartment complex knocking on doors and asking the residents if this was where she lived. The apartment manager noticed the patient and let her into her daughter's apartment.

Interview on 09/27/17 at 1:20 p.m. with S5MHT revealed when asked if he reported to Transportation A where patient #1 was to be transferred to, he responded he could not remember.

On 09/27/17 at 2:25 p.m. a telephone interview was conducted with S6Transportation Owner. When asked if any staff from the IOP had directed the transportation driver to take the patient to the nursing home, she replied "no" and since they were familiar with the patient, they transferred her back to her home where they had always picked her up. When asked if they accompanied the patient to the door, S6 replied the patient's apartment was located on the end and they would drop her off on the sidewalk leading to her apartment and the patient always went in.

The hospital failed to follow their Discharge Planning Policy and Procedure and directly communicate to Transportation A that patient #1 was to be taken to the nursing home instead of her former place of residence.