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ADVENTHEALTH ORLANDO 601 E ROLLINS ST ORLANDO, FL 32803 Jan. 25, 2018
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review, and facility's policy and procedure review, the facility failed to provide an appropriate discharge for 1 of 10 patients reviewed for discharge planning (#1).

Findings:

Patient #1 was admitted on [DATE]. The triage documentation dated 8/26/17 showed patient #1's chief complaint was lower back pain, height 5 feet, and estimated weight was 510 pounds (lb.). The emergency department (ED) physician sheet dated 8/26/17 read, "The patient presents with low back pain ...Pt (patient) sts (states) increased difficulty ambulating and standing at home.." On 8/27/17 at 1:23 PM, the physician wrote, "Spoke with social worker who advises pt has a working plan in place for safe discharge. Patient wants long-term SNF (skilled nursing facility) placement..."

The Case Management Discharge Planning assessment completed in the ED on 8/27/17 read, "Pt states he lives by himself and completes ADLs (activity of daily living) by himself. Pt states has wheelchair in order to get around as he does not walk....Pt states he would like to go to an ALF (assisted living facility) or nursing home for long-term placement. Pt states he doesn't want to live by himself anymore and wants someone else to care for him."
The Case Management Discharge Planning assessment dated [DATE] showed anticipated discharge date on 9/12/17 to an ALF.

Physical therapy progress notes dated 9/19/17 read, "Recommend SNF upon D/C [discharge] and can further benefit from skilled PT to maximize functional mobility safely." Functional devices recommended for D/C were a Hoyer lift and a reacher. Patient #1 was discharged to an ALF on 9/19/17.

On 1/25/18 at 5:15 PM, an interview was conducted with Case Manager (CM) A, the Director of Case Management, assistant Director of Case Management, and Risk Managers. CM A said patient #1 was admitted to the hospital from home with multiple medical conditions. The patient was a bariatric patient and weighed over 500 lb. CM A said initially when asked if the patient was going to return home, patient #1 said he could not walk. A physical therapy (PT) evaluation was done, and PT said the patient was very limited with mobility and recommended SNF placement. Patient #1 was informed about the recommendation, and was in agreement.
CM A said in the Orlando area there were not may facilities that accepted patients with that weight. Weight limit was 350 lb. CM A said the hospital sent referrals to Orlando area SNFs, and the patient was denied for various reasons. Referrals were sent statewide, and sent to New York facilities that specialized in bariatric patient, but the hospital was was told that the facility was unable to handle someone with that weight. CM A said they exhausted the SNFs, and the alternate plan was for D/C to an ALF. The AHCA assessment form 1823 was completed for the chosen ALF to review. He said the ALF felt they could assist, but needed a bariatric bed. This was arranged. Orders for home health services, a home health nurse, and physical therapy (PT) was also arranged. CM A said he believes that this was a safe and appropriate discharge at this time. He said he was told by the ALF that they were able to accommodate patient #1 and take care of his needs. When it was pointed out to CM A that if the patient required total care in five areas of ADLs, he would not be an appropriate pt for the ALF, the CM said patient #1 could bathe himself, self-transfer, feed himself, could ambulate, but chose not to ambulate. The CM director said she "feels" that everything was done for this patient to get him to a safe place. The CM assistant director said she believe discharge to the ALF was a safe discharge and a "well informed decision across the care team."

Review of the AHCA assessment form to the ALF (1823) for patient #1 showed the following: nursing/treatment/therapy services: total care. ADL: total care for ambulation, bathing, dressing, self- care and transferring, making patient #1 an inappropriate candidate for an ALF.

The facility's policy "Discharge Planning- Inpatient", effective date 1/23/17, read, "The purpose of this policy is to provide interdisciplinary discharge planning individualized to the patient's needs....The discharge plan provides appropriate and effective use of health care resources, matching patient needs to the most appropriate level of care within the continuum."