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5501 OLD YORK ROAD

PHILADELPHIA, PA 19141

TRANSFER OR REFERRAL

Tag No.: A0837

Based on review of medical records (MR), review of facility policy and interview with staff (EMP), it was determined the facility failed to transfer patient to the appropriate facility, as needed for follow-up care for one of one medical record reviewed (MR1).

Review on October 3, 2018, of facility policy, " ... Discharge Planning," dated June 1, 2018, revealed, " ... I. Purpose: To provide guidelines for discharging patients to an appropriate setting and with provision for aftercare treatment that will provide continuity of care. II. Policy: a. Discharge Planning is an organized multidisciplinary process that is coordinated by the assigned social worker/case manager ... III. Procedure/Guidelines: ... k. Aftercare plans - The case manager and ... are responsible for fully completing the aftercare plan. The case manager should document progress notes in the chart regarding aftercare plans ... The aftercare appointment will be scheduled by the case manager and will be indicated on the patient's discharge instructions ... m. ... Coordination regarding the time of discharge and the destination should be coordinated with nursing personnel... ."

Review on October 3, 2018, of facility policy, " ... Discharge Planning," dated June 30, 2008, revealed, " ... III. Procedure: ... 7. ... Final Plans for the discharge will be documented on the Interdisciplinary Discharge Record or in the case of a transfer on the Transfer Form ... ."

Review on October 1, 2018, of MR1's " ... Patient Discharge Instructions," dated August 22, 2018, revealed, " ... Disposition Type: Skilled Nursing Unit, Disposition Address: Harborview Rehabilitation and Care Center ... Doylestown ... ."

Review on October 1, 2018, of MR1's, "Social Work Narrative Note," dated August 22, 2018 at 4:30 PM, revealed, " ... SW [social worker] completed transport request and notified front desk staff and on call Resident on Tower 7 that patient was being discharged to Willow Terrace at 6:00 PM."

Review on October 1, 2018, of MR1's, "Care Manager Narrative Note," dated August 22, 2018 at 9:21 PM, revealed, " Received a call from Tower 7 Nursing staff stating that Harbor View Nursing Home did not accept the patient when ... arrived at the facility ... Per the nursing staff, the facility told them they did not receive information prior to patient's arrival ... ."

Interview on October 2, 2018, at 10:40 AM with EMP3 confirmed they were on duty the evening the patient was transferred. EMP3 confirmed the ambulance driver was notified to transport the patient that evening at 6:00 PM to Willow Terrace. EMP3 reviewed MR1 and confirmed there was documentation stating the patient was to be transferred to Harbor View at the time of discharge. EMP3 confirmed with the ambulance driver to transport the patient to HarborView. Continued interview with EMP3 confirmed nursing staff did not contact on the on-call social worker to confirm the discharge plan.

Interview on October 2, 2018, at 1:30 PM with EMP8 confirmed the social worker providing care to MR1 did not update the discharge plan with the most current nursing home placement information. EMP8 confirmed the patient was transferred to the wrong facility and was refused admission upon arrival. When ambulance personnel contacted the facility for instructions regarding where the patient should go, the facility directed the patient to the closet Emergency Department for care and treatment.