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Based on review of records and interview with staff, the facility failed to ensure that the patient or patient's representative had the right to make informed decisions regarding care for 1 of 1 patient whose record was reviewed, as the plans to transfer Patient #1 to another facility were not discussed with family and a choice of facilities was not provided.

Findings were:

Policy PC 229, entitled Ongoing Interdisciplinary Discharge Planning was reviewed; section 4 of the policy states that " Patients and families participate actively in discharge planning. " Section 5 states that " Discharge needs are continually assessed by case management team in light of (5.8) Patient and family coping and adaptation adjustment. " Section 7.4 states that discharge resources are " communicated to all involved parties, including the patient ' s family. "

Policy PC 225, entitled Outgoing Interfacility Transfers/Discharges states under Section II Patient Transfers (F.6) that " Patients and families are appropriately educated concerning transfer and actively involved in transfer decision-making when possible. "

Review of Patient #1's medical record revealed that on 7/13/10, Patient #1 was accepted by another facility for skilled nursing care. There was no documentation in the record that the patient ' s spouse or adult child was notified. The Discharge Choice form has a line for patient signature; this was not signed by the patient or family. The signature line contained the comment that a report was given to a staff member of the receiving facility. This statement was not signed by anyone. The Patient Transfer Form was signed by the patient; however, under the Mental Status column, " Forgetful " was checked. Additionally, on 7/14/2010, nursing notes indicate that the patient had " decreased cognition. " According to the family, they did not know Patient #1 was being transferred until the time of the transfer, and then only because the patient was talking to the family member on the telephone. Further review of the medical record of Patient #1 revealed that a form entitled Patient Choice Letter, which allows patients to choose a specific provider for their follow-up care, was not present in the record.

An interview was conducted on 10/18/2010 in a facility conference room with Staff #1, the Director of Case Management, and Staff #2, the nurse in charge of the patient at the time of transfer. Staff #2 indicated that the patient was on the phone with a family member at the time the patient was being transferred; the family member did not know where the patient was going, and was not aware of the transfer. According to Staff #2, they are supposed to try to contact a family member when a patient is leaving the facility. Additionally, Director of Case Management, Staff #1, verified that the patient and family were not provided with the Patient Choice Letter.

Based on review of records and interview with staff, the facility failed to ensure that a registered nurse (RN), social worker, or other appropriately qualified personnel developed a discharge plan for 1 of 1 patient whose record was reviewed.

Findings were:

Facility policy PC 229, entitled Ongoing Interdisciplinary Discharge Planning, was reviewed. Section 1.3.4 of the policy states that the " Social Worker assists patients, families or guardians with psychosocial and financial issues which impact the continuity of care. The staff facilitates placement and alternate levels of care along the continuum including ....rehabilitation and long-term care facilities. "

Review of the medical record of Patient #1 revealed that there was no documentation that facility staff developed or supervised a discharge plan. This was verified with the Director of Case Management, Staff#1, in an interview conducted the afternoon of 10/18/10 in a facility conference room.

Based on review of records and interviews with staff, the facility failed to counsel family members to prepare them for post-hospital care for 1 of 1 patient whose record was reviewed. The family of Patient #1 was not informed of a transfer to another facility.

Findings were:

Policy PC 229, entitled Ongoing Interdisciplinary Discharge Planning was reviewed; section 4 of the policy states that " Patients and families participate actively in discharge planning. " Section 5 states that " Discharge needs are continually assessed by case management team in light of (5.8) Patient and family coping and adaptation adjustment. " Section 7.4 states that discharge resources are " communicated to all involved parties, including the patient ' s family. "

Policy PC 225, entitled Outgoing Interfacility Transfers/Discharges states under Section II Patient Transfers (F.6) that " Patients and families are appropriately educated concerning transfer and actively involved in transfer decision-making when possible. "

Review of Patient #1's medical record revealed that on 7/13/10, Patient #1 was accepted by another facility for skilled nursing care. There was no documentation in the record that the patient ' s spouse or adult child was notified. The Discharge Choice form has a line for patient signature; this was not signed by the patient or family. The signature line contained the comment that a report was given to a staff member of the receiving facility. This statement was not signed by anyone. The patient transfer form was signed by the patient; however, under the Mental Status column, " Forgetful " was checked. Additionally, on 7/14/2010, nursing notes indicate that the patient had " decreased cognition. " According to the family, they did not know Patient #1 was being transferred until the time of the transfer, and then only because the patient was talking to the family member on the telephone.

An interview was conducted on 10/18/2010 in a facility conference room with Staff #2, the nurse in charge of the patient at the time of transfer. Staff #2 indicated that the patient was on the phone with a family member at the time the patient was being transferred, and that the family member did not know where the patient was going, and was not aware of the transfer. According to Staff #2, they are supposed to try to contact a family member when a patient is leaving the facility.

Based on review of records and interview with staff, the facility failed to provide a list of skilled nursing facilities (SNF) that are participating in the Medicare program and that serve the geographic residential area of 1 of 1 patient whose record was reviewed.

Findings were:

Review of the medical record of Patient #1 revealed that a form entitled Patient Choice Letter, which allows patients to choose a specific provider for their follow-up care, was not present in the record. This was verified with the Director of Case Management, Staff #1 in an interview conducted the afternoon of 10/18/10 in a facility conference room.