The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on staff interviews and facility documents, the facility failed to transfer 1 of 10 sampled patients (Patient #10) to an appropriate facility that could meet his need for skilled nursing services. This inappropriate transfer delayed the rehabilitation process for Patient #10. The findings are:

A. On 07/ 25/14 at 3:15 pm, the Clinical Manager for Social Work and Utilization Review at the transferring hospital stated, "I had an awareness that the Social Work Department was trying to get Patient #10 to be discharged to a skilled nursing facility [SNF]. We had exhausted calling just about every SNF in town. The Social Work assistant said, 'What about [the psychiatric hospital]?' We did not know at the time that there is the psychiatric hospital and a skilled nursing facility with the same name. We thought we were calling the skilled nursing facility but we were actually in contact with the psychiatric hospital. We had Googled the name and contacted the wrong facility. We told them that we had a skilled nursing client. We emphasized that on every communication. Patient #10 was transferred to the psychiatric hospital. His son subsequently learned that it was a psychiatric hospital. There was communication as to why the psychiatric hospital accepted this patient as a lateral transfer when we were sending this patient to a SNF. When the family learned he was at a psychiatric hospital, they worked to get him back over here. On 05/14/14, Patient #10 was discharged from the transferring hospital. The discharge planner called me on 05/16/14 to tell me that Patient #10 was at another psychiatric hospital. He returned to the previous facility on 05/22/14."

B. On 07/29/14 at 9:30 am, the Director of Assessment and Referral
of the receiving facility stated that the facility makes audio recordings of any calls made to the facility's intake line. A recording of a conversation between the discharge planner at the transferring hospital and the assessment and referral specialist occurred on 05/13/14 at 3:04 pm. The discharge planner for the transferring hospital stated, "I am interested in your long term care facility. I have a [AGE]-year-old gentleman who has been in our hospital and we have been trying to get him into a rehab facility just because he's pretty deconditioned, but it's looking now like we may have to look at long term care. Do you have any open beds for males?" The assessment and referral specialist at the receiving hospital replied, "For long term that wouldn't be us, we are a short term facility." The discharge planner replied, "Well, we would try either one." The assessment and referral specialist replied, "OK, we actually do [have open beds]. If you could fax us an information sheet, demographics, any behavior or psych notes that you have and I can review it and present it to our on-call psychiatrist." The discharge planner said, "OK. who is your on-call pyschiatrist?" He replied, "It is Dr.[name of psychiatrist]." The assessment and referral specialist gave the discharge planner the fax number. The discharge planner replied, "I will fax that over in just a little bit. And when will l know something?" The assessment and referral specialist replied, "Once I get it and review it and present it to the physician I will know in about 15 to 20 minutes. As soon as I know something I will give you a call back." The discharge planner replied, "Thanks." The call ended at 3:05 pm.

C. On 07/29/14 at 1:45 pm, the assessment and referral specialist stated, "The only other communication besides the call that was taped was that the discharge planner faxed over the patient's chart and paperwork. I reviewed it and I called the on-call doctor to present the patient for possible admission. The intake form revealed nothing concerning skilled nursing, only behavioral issues. I never got an inkling that this facility would not meet the patient's needs. When I presented the patient's information to the physician, it was completely behavioral-oriented."