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MOUNT SINAI MEDICAL CENTER 4300 ALTON RD MIAMI BEACH, FL 33140 July 18, 2012
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
Based on record review and interview, the facility failed to ensure that patients are discharged to another setting [Skilled Nursing Facility and/or Rehabilitation place] along with necessary completed forms to facilitate continuity of care in 5 (#1, #3, #4, #5 and #6) of 14 sample patients.

The findings include:

Clinical record review of Sample Patient (SP)#1 conducted from 7-16-12 to 7-18-12 revealed that he was transferred to a Skilled Nursing Facility on 5-18-12. Case Manager documentation and Physician Orders showed SP#1's change of discharge disposition from home with Home Health Care to discharge to a Skilled Nursing Facility [SNF].

The Medical Certification for Nursing Facility/Home and Community-Based Services [MCNF/HCBS] form used to provide information for patients discharged to SNF and other community-based facilities has two pages: one page to be completed by the Physician and the second top page to be completed by the Registered Nurse [RN], the bottom page by the Social Worker.

Physician documentation on SP#1's MCNF/HCBS form showed no information as to which facility he is going to; no discharge date , incomplete demographics and no entry on the type of care recommended which showed " must be completed and signed. "

RN documentation on the Medication Reconciliation Discharge Form showed SP#1's medication list prior to admission, inpatient medications and new medication orders. Documentation showed which medications are to be continued and/or discontinued. The bottom part showed SP#1's Physician signature but without the RN's signature.

Interview with Case Manager I conducted on 7-17-12 at 225pm revealed that documents sent to the SNF include the transfer form, the Medication Reconciliation Discharge Form which is always signed by the RN and the Physician, the last MAR [Medication Administration Record] and the Physician Certification Statement for Medicare patients only.

Interview with the Director of 7Main conducted on 7-17-12 at 230pm revealed that the RN should sign the medication reconciliation discharge form.

Interview with Staff RN I conducted on 7-17-12 at 245pm revealed that the transfer form with the copy of the last MAR and the medication reconciliation discharge forms are sent to the SNF. She stated that the RN should sign the medication reconciliation discharge form. She added that oral report is given in addition to the documents sent for patients discharged to Rehab but not to SNFs.

Interview with Case Manager II conducted on 7-17-12 at 310pm confirmed the needed missing information on SP#1's transfer form. He also confirmed that the medication reconciliation discharge form was not signed and dated by the RN. He added that the Physician and the RN should sign the medication reconciliation discharge form.

Interview with Staff RN II conducted on 7-18-12 at 1125am revealed that she could not recall discharging SP#1 but confirmed her signature on SP#1's medication reconciliation discharge form. She confirmed that she missed to sign and date the form. She stated that she should sign and date the medication reconciliation form.

Clinical record review of SP#3 conducted from 7-16-12 to 7-18-12 revealed that he was discharged to a Rehabilitation place. Documentation showed missing information on the MCNF/HCBS form: no admission/discharge date s, incomplete demographics, no type of care recommended and no Social Worker assessment.

Clinical record review of SP#4 conducted from 7-16-12 to 7-18-12 revealed that he was discharged to a SNF. Documentation showed missing information on the MCNF/HCBS form: no admission/discharge date s, no demographics, no type of care recommended and no Social Worker assessment. Documentation on the medication reconciliation discharge form showed no RN signature, date and time.

Clinical record review of SP#5 conducted from 7-16-12 to 7-18-12 revealed that she was discharged to a Rehabilitation place. Documentation showed missing information on the MCNF/HCBS form: no named facility where to transfer patient, no named facility where patient came from, no admission/discharge date s, no demographics, no type of care recommended and no Social Worker assessment. Documentation on the first page of the medication reconciliation discharge form showed a check mark indicating a telephone order received by the RN on 5-10-12. Documentation on the second page showed a check mark indicating a telephone order but with no RN signature, date and time. There was no Physician signature from the date the telephone order was received on 5-10-12 to the last survey date on 7-18-12.

Clinical record review of SP#6 conducted from 7-16-12 to 7-18-12 revealed that she was discharged to a SNF. Documentation showed missing information on the MCNF/HCBS form: no admission/discharge date s, no demographics and no Social Worker assessment. Documentation on the medication reconciliation discharge form showed no RN signature, date and time.

Interview with the Manager of Case Management conducted on 7-18-12 at 1145am confirmed the needed missing information in the transfer forms of SP#1, #3, #4, #5 and #6. He concurred that the missing information were important for the receiving facility to know.

Interview with the Director of 7Main conducted on 7-18-12 at 1145am confirmed the missing information in the transfer forms of SP#1, #3, #4, #5 and #6 and emphasized the importance of indicating "the level of care recommended by the Physician." She concurred that the form showed "must be completed and signed."

Documentation on an Internal Email presented on 7-18-12 by the Manager of Accreditation Services showed "a list of documents to print/copy for transferring patients to Rehab, SNF or to another acute care hospital. The following are required to be provided as part of the medical history of the patient when transferring patients. Please provide copy of the following:...Transfer Form completed...Last 48 hours MARs( Medication Administration Record) ..."

Interview with the Manager of Accreditation Services conducted on 7-18-12 at 210pm confirmed that 5 of the 5 sample patients transferred to the different Skilled Nursing Facilities and Rehabilitation places had transfer forms that were not complete, validating the fact that transfer forms sent to the receiving facilities should be complete with all necessary information.