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Based on a review of clinical records, facility policy and procedure and interview with administrative and clinical staff, it was determined the Condition of Participation is not met as evidenced by the hospital failure to ensure patients who were transferred to skilled nursing facilities had adequate discharge planning to ensure the receiving facility had the necessary information needed to meet the patient needs for 5 (Patients #1, #3, #4, #5 and #6) of the 7 patient records reviewed.

The findings include:

1. Interview with 2 of the staff Resource Managers, on 3/11/10 at 10:00 a.m. and 12:00 p.m., revealed the following information. The patient is assessed by the Resource Manager as to the needs at discharge. The patient and or family are interviewed to assist in the determination of the patient's needs at discharge. The patient and family are given information about the appropriate facilities (example, if the patient has a specific need, which facilities are able to meet that need). The family is encouraged to tour the facilities and choose one. Once it's been determined which facility is to be utilized a referral is given to that facility. The Skilled Nursing Facility (SNF) sends a staff member to evaluate the patient and determine if they will accept the patient for admission. The Resource Manager indicated they would document the acceptance by the SNF in the case management notes. The Resource Manager further stated they would not document the visit to the patient by the SNF staff nor would the floor nurses. The SNF staff does not document their visit in the hospital clinical record (other outside staff do, such as Hospice staff). The Resource Manager arranges transportation to the receiving SNF and makes copies of the parts of chart that are to be sent with the patient. This includes the required form 3008 for transfer to the nursing home. Both Resource Manager stated they do not document what pieces of the chart are sent to the nursing home.

Both Resource Managers indicated during their interview that the floor nurse gives report to the nursing home nurse about the patient at the time of transfer.

2. Patient #3 was admitted to the hospital on 1/26/10 and discharged to a SNF on 2/12/10. The patient had vocal paralysis, had just had surgery resulting in a temporary tracheostomy (a hole in the throat to allow the patient to breathe) and a feeding tube place in the abdomen (PEG tube) to provide nutritional feedings. Review of the doctor's part of the AHCA Medserv-3008 form for transfer and communication with facilities revealed documentation of the tracheostomy and the Peg Tube on page 1 of the form. It also listed the patient needs for "Trach care and PMV valve" (passey muir valve that allows the patient to speak). The first page indicated there were to be "Bolus (type of tube feeding) tube feeds as per attached."

Review of the 2nd page, filled out by the nurse, did not indicate the need for tracheostomy care. It did indicate the patient was to have nothing by mouth and was to receive feedings via the PEG tube. The patient was transferred to the SNF with a Foley catheter to drain urine. The form was incomplete for long range plans, adjustments to illness, or comments. There was no documentation indicating the type, amount, or frequency of the tube feeding. A list of medications was present in the discharge information. All medications were identified as being oral for the route of administration.

Interview with the Resource Manager, on 3/11/10, at 11:50 a.m., indicated additional paperwork was sent with the patient to the nursing home which included the orders for the tube feeding. She agreed she did not document specifically what paper work was sent with the patient. She stated she did not call a report to the nursing home staff, as the floor nurse "Does it." During this interview, the Resource Manager further indicated she had spoken with the Director of Nursing (DON) at the nursing home 7 times on the day of discharge about this patient. She agreed she did not document any of the conversations with the Director of Nursing in the case management notes for this patient. She stated she was unsure if the patient was taking any of the ordered medications orally.

An interview with the nurse who discharged this patient from the hospital was done on 3/11/10, at 12:30 p.m., and she revealed the patient was receiving all of the medications through the PEG tube. She indicated a copy of the records is made by case management to give to the patient at the time of transfer. She agreed this is not documented. Sometimes it's given to the transport person by the desk staff and she is unaware of this. She stated she did not call the nursing home with a report as it is the responsibility of the case managers to call report.

Interview with the Chief Nursing Officer, on 3/11/10, at 12:50 p.m., revealed this is not a part of the discharge policy for the nurses to call report to the SNF. She agreed during the interview that it was the practice of the facility to call report to the nursing home receiving the patient, but policy did not require it. She agreed there was no documentation about which parts of the patient chart are copied and sent to the nursing.

Interview, on 3/11/10, at 3:00 p.m., the Chief Nursing Officer stated that SNF staff come to the hospital to screen patients prior to accepting them for admission, and are not permitted to review the patient's medical record because "It is a privacy issue."

Review of the policy and procedure titled "Transfer of Patients: Extended Care/Skilled Nursing/Rehab/Assisted Living Facilities" includes the following: "4. Intake coordinators from receiving facilities are notified of referral by hospital Resource Manager. 5. Chart is reviewed by Intake coordinator and feedback regarding acceptance is given to the hospital's resource manager/designee."

2. Patient #6 was admitted to the hospital on 2/18/10. The notes on the collaborative care worksheet indicated the patient was a hospice patient and hospice would make all discharge arrangements for the patient. On 2/19/10 in the progress notes, the documentation revealed the patient had revoked their hospice benefit for regular Medicare coverage. There was no documentation about this by the Resource Manager for this patient. There was no documentation about the discharge plan for this patient until 2/22/10, the day of discharge, about the discharge plan being changed. There was no documentation of any paper work being sent to the nursing home with this patient.

3. Patient #4 was discharged from the hospital to a SNF on 2/2/10 with a PICC (Percutaneously Inserted Central Catheter) line in place for the administration of intravenous antibiotics. This line is left in place and reaches from the insertion site into a vein in the elbow and is threaded through this vein almost into the heart. There was no mention of this intravenous catheter noted on the transfer form 3008. There was also no evidence for instruction in the care of this catheter. On the sheet labeled "Discharge instructions" under special equipment is documented the PICC line and IV (intravenous) therapy. There were no specific instructions given about the use and care of the equipment. There was no documentation in the record what paper work was sent with the patient to the SNF.

4. Review of the medical record, on 3/11/10, at 2:00 p.m., revealed Patient #1 was admitted to the hospital on 1/14/10 with diagnoses of Status Post Fall, Fracture 10th Rib, Pneumothorax and Positive Urine Culture.

On 1/19/10, it was noted by the Dietician that the patient had "Very inconsistent PO (oral) intake, often 0% of tray eaten, decreased appetite secondary to pain." The last albumin laboratory study, on 1/14/10, is recorded within normal limits at 4.0. The dietician identified a plan to check albumin and prealbumin obtain current weight and encourage intake. A "Physician Query Form" dated 1/22/10 documented Albumin 2.8, prealbumin of 10, BMI 18; and identifies a diagnosis of " Moderate Malnutrition."

Physician orders dated 1/20/10 states "D/C (discharge) to SNF (skilled nursing facility)." A "Discharge Assessment/Social Service" note, dated 1/20/10 at 1427 (2:27 p.m.), indicates a SNF accepted the patient for admission; a face sheet was faxed to the SNF at 1507 (3:07 p.m.); and discharge took place at 1510 (3:10 p.m.).

A nurse's note dated 1/20/10 at 1530 (3:30 p.m.) stated, "Discharge, report called, Heplock removed intact." A "Braden Scale for Predicting Pressure Score Risk", completed by the discharge nurse on 1/20/10, scores nutrition (usual food intake pattern) as "3. Adequate - Eats, over half of most meals" and "Occasionally will refuse a meal." The "Nursing/Social Work Assessment" Form 3009, page 2, without a date or signature, indicates feeding as "Tray set up only."

The Discharge Summary completed by the physician on 1/22/10 states "The patient also exhibited protein malnutrition with prealbumin of 10, glucose of 9 (BUN 9), potassium was slightly on the low side 3.3."

During an interview, on 3/11/10, at 12:30 p.m., the Director of Resource Management stated the Discharge Summary is not sent to the SNF. The Director also stated that Form 3008 and several days of nurse's notes are sent to the SNF on discharge of a resident; she stated no record is kept indicating what part of the medical record is copied and forwarded to the SNF. No hospital policy was available to identify what records should be forwarded as part of the discharge plan.

5. Review of the medical record, on 3/11/10, at 11:30 a.m., revealed Patient #5 was admitted to the hospital on 2/13/10 with diagnoses of Status Post Fall and Head Injury. Emergency room records indicate a 2cm (centimeter) laceration to left forehead was repaired with 4 sutures at 0315 (3:15 a.m.), with pressure dressing applied due to "Still bleeding"; and a Foley catheter #16FR, 10 ml (milliliters) of sterile water in balloon, was inserted at 0748 (7:48 a.m.).

A Discharge Assessment/Social Service note dated 2/16/10, at 12:00 p.m., states discharge to Skilled Nursing Facility (SNF) for Physical Therapy (PT). Form AHCA 3008 entitled "Medical Certification" Page 1, signed as completed by the physician on 2/16/10, indicates principal diagnosis as "Weakness", "Meds per MOR (Medication Observation Record), PT/OT(Physical Therapy/Occupational Therapy) to eval & treat @ (at) rehab", "Soft diet", and "See copied chart" for history, physical and laboratory findings. Section "H", "Treatment and Equipment Needs (attach orders)" was blank relating to catheter care and wound care. Page 2 of this form indicated "Hematoma skin tear" and "Catheter - indwelling."

Nurse's notes dated 2/16/10 stated "Diagnosis Fall, hematoma (Forehead Left)", "IV Access: R FA (right forearm), NS (normal saline) @80ml/hr (at 80 milliliters per hour)" and urinary catheter (size not indicated). A note at 12:00 p.m., states "No change in baseline assessment no distress." A note at 1335 (1:35 p.m.) states "Pt (patient) left via Ambitram (local transportation service)."

During an interview, on 3/11/10, at 12:30 p.m., the Director of Resource Management stated "We certainly missed that one", referring to the patient sutures to the left forehead not being reported to the SNF. When questioned regarding the nurse's progress and discharge note(s) of 2/16/10, the Director agreed that no report regarding the patient's condition was documented as being given to the SNF, it appeared that the patient was sent to the SNF on IV fluids (without a physician's order), and there was no indication that the patient's left forehead wound had a treatment order.