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.

BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER 101 HOSPITAL ROAD PATCHOGUE, NY 11772 Aug. 6, 2015
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, the facility failed to establish time limits for the Restraint Policy.

This failure places all patients at risk for prolonged restraint and seclusion.

Findings:

Review of the facility policy that is "untitled" dated [DATE] which addresses restraint and seclusion, lacked the required age appropriate time limits for patients placed in Four (4) Point Violent Restraints or Seclusion.

During interview with staff #6 on 8/6/15, she stated , "I know it was in the policy, maybe it got left out".
VIOLATION: PATIENT RIGHTS Tag No: A0115
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Based on observations, record review and staff interview, the facility failed to investigate and resolve patient complaints and grievances, to protect the patients' personal information, and to ensure the patients' right to be free from unnecessary physical restraints.

These failures place all patients at risk for not having the ability to exercise their patient rights while receiving care in the facility.

Findings:

The facility failed to delegate the responsibility of the grievance process to a committee.
(See Tag A 119)

The facility failed to ensure the maintenance of patient grievances and complaints as per facility Policy and to maintain a Grievance / Complaint Log
(See Tag A 123)

The facility failed to ensure the protection of patient personal information.
(See Tag A 143)

The facility failed to establish time limits for the restraint Policy.
(See Tag A 171)

The facility failed to monitor a patient in restraints to determine if the patient's behavior, which was no longer a threat to self, staff members, or others, warranted the continued use of restraints.
(See Tag A 174)

The facility failed to ensure timely orders and face to face interviews for a patient in restraints and to ensure accurate documentation of a patient placed in restraints.
(See Tag A 175)

The facility failed ensure that staff had accurate knowledge of the requirements for a patient placed in violent restraints.
(See Tag A 178)
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VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
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Based on documentation review and interview, facility Quality Management failed to: a) provide oversight for the patient complaint / grievance process, b) track and trend pertinent patient complaint information, and c) develop an ongoing improvement plan.

The lack of oversight, data collection and improvement plan puts patients at risk for repeated breeches in patient safety and quality of care.

Findings:

a) Upon request for the patient complaints and grievances on 08/04/15, it was disclosed at 1:30PM by Staff #6 (Accreditation Manager) that the facility was unable to locate the patient grievances / complaints or the Grievance Log.

During interview on 08/04/15 at 3:45PM with Staff #15 (Chief Nursing Officer), it was discovered that facility Quality Management does not review the grievances / complaints, and only collects the number of complaints. As per Staff #15, there is no Quality Management oversight and no grievance committee.

Review of facility Policy titled "Grievance Policy and Procedure" revealed on Page 5 that the "VP Development and External Relations (or designee)" is responsible to chair the Grievance Panel and maintain Minutes and documentation related to the Meetings.

On 8/4/15 at approximately 3:50PM, when asked how often the Meetings were scheduled, Staff #15 replied "They are not scheduled. They only happen as needed, upon request of the Patient Advocate", and "I can't remember when the last one was".

The facility did not produce any evidence of Grievance Panel Meeting Minutes for review.

b) On 08/04/15, upon request for the Tracking and Trending Reports for the grievances / complaints, Staff #15 was only able to produce a "percentage" graph that showed how many reports were completed. Staff #15 further stated "We only track them quantitatively, we do not look at them qualitatively."

c) During the interview on 08/04/15, Staff #15 could not provide any evidence of any type of ongoing quality improvement plan related to patient concerns due to the lack of monitoring or tracking and trending of patient complaints and grievances.

These findings were confirmed by Staff #15, in the presence of Staff #17 (Chief Quality Medical Officer).
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VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on record review, document review and interview, the facility failed to ensure that "all Medicare beneficiary patients / patient's representatives were provided with the standardized notice "An Important Message from Medicare about Your Rights" (IM) in accordance with the facility policy and procedure. This was evident in four (4) out of nine (9) records reviewed for patients who were Medicare beneficiaries.

Findings:

a) Review of the facility's Policy and Procedure titled "Discharge Appeal Rights: Distribution of the Important Message from Medicare", dated 04/04/14, revealed that the IM notifies the patient of their hospital discharge appeal rights. This is directed for all Medicare and Managed Medicare insured patients.

When the beneficiary is unable to comprehend the notice, the IM must be delivered by Registration to the beneficiary's representative and be signed within two (2) business days.

Review of the Medical Record (MR) for Patient L documented that the patient was admitted on [DATE] at 10:50AM with diagnoses of [DIAGNOSES REDACTED]

Chart review on 08/05/15 at 1:50PM revealed that there was no Important Message (IM) in the chart, eight (8) days after the patient was admitted .

An interview conducted with the patient's son on 08/05/15 at 1:55PM revealed that he was the patient's Health Care Proxy and the emergency contact. When asked if he was aware of his right to appeal the patient's discharge, he said no.

During an interview with Staff #11 on 08/05/15, the Care Manger, who was handling this case, advised that she did not yet place an IM in the patient's chart and advised that the son was there daily, but she did not advise him of the patient's right for discharge or have him sign the form as required.

Staff #11 also advised that she does not check the record for the admission IM until the patient is ready to be discharged . She confirmed that once the patient is admitted , it is the job of the Case Manager and/or the Social Worker to make sure that the IM is signed and in the patient's record.

Review of MR for Patient T documented that the patient was admitted to the facility on [DATE] and was discharged on [DATE] at 12:00PM. The patient was alert and oriented and was in the hospital for only two (2) days.

An interview conducted on 08/06/15 at 11:40AM revealed that the patient received the Patient Rights upon admission, and that she was aware of the discharge process as she had previously been in the hospital.

Review of the Medical Record revealed that there was no evidence of an IM within upon admission.

b) The Policy Titled "Discharge Appeal Rights" dated 04/04/14 documents that the follow up IM is required," to be delivered to the beneficiary as far in advance of discharge as possible, but no more than 2 calendar days before the planned date of discharge..."

Review of the MR for Patient R documented that the patient was admitted on [DATE] and received an IM letter upon admission. No additional IM letter was evident in the Medical Record prior to the patient's discharge on 07/04/15 as required.

Similar findings were noted in the Medical Record for Patient S.
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VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
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Based on document review and interview, the facility failed to delegate the responsibility of the grievance process to a committee.

The failure to develop a committee responsible for complaint / grievance investigation and resolution places all patients at risk for not having a complete and comprehensive investigation of their concerns.

Findings:

On 08/04/15 at 1:30PM during an interview with Staff #6 (Accreditation Manager), it was revealed that the facility was unable to locate any complaints or grievances from January 2015 to mid-May 2015. She stated they were "missing".

On 08/04/15 at 3:45PM during an interview with Staff #15 (Chief Nursing Officer), the staff member stated that "the Patient Care Advocate is responsible for the complaints and grievances". When asked if a committee reviews the complaints and grievances, she replied "No". Staff #15 further stated "the Patient Advocate tells me how many and what type of complaints / grievances there are and I keep track of them quantitatively, but I do not review them for content".

On 08/04/15 at 3:50PM Staff #17 (Chief Quality Medical Officer), who was present during the time of interview of Staff #15, stated "Am I correct in understanding that this is a Regulatory requirement that we are supposed to be tracking and trending?"

Neither staff member could verbalize the knowledge of the Federal requirement regarding the tracking and trending of complaints / grievances, the investigations and the outcomes.
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VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
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Based on documentation review and interview, the facility failed to: a) ensure the maintenance of patient grievances and complaints as per facility Policy, and b) maintain a Grievance / Complaint Log.

The failure to maintain these records places all patients at risk for incomplete investigations and non-resolution of patient issues and concerns.

Findings:

a) During an interview on 08/04/15 at 3:45PM with Staff #15 (Chief Nursing Officer), when asked for all complaints and grievances for the year 2014, replied "there aren't any, we cannot find them". When asked which years they did have, she replied "we have nothing".

It was also stated that there was a change in the facility Patient Advocate staff member who was assigned the complaints / grievances, the office had been "cleaned out", and the whereabouts of the investigations where unknown.

Review of the facility Policy titled "Control of Records" dated 09/02/13 documents on Page 6 that patient grievances and complaints are to be kept by the Patient Advocate for a period of eight (8) years.

b) On 08/04/15 at 3:45PM during an interview with Staff #15, when asked for the Grievance / Complaint Log for the past eight (8) years up to present day, she replied "we are unable to locate that either".

Review of the facility Policy titled "Patient Complaints" updated 04/30/13 revealed that the Policy lacks instructions for keeping a Log with complaint and investigation information.
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VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
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Based on interview and document review, the facility failed to ensure the protection of patient personal information.

The facility's failure to ensure the patient's right to privacy places all patient at risk for disclosure of personal information.

Findings:

During an interview with Staff #6 (Accreditation Manager) on 08/04/15 at 1:30PM, upon discovery of the missing grievances / complaints stated "I was told they were accidentally shredded by a Volunteer when she cleaned out the office for the new Patient Advocate".

On 08/04/15 at 3:45PM while inquiring about the missing grievances / complaints during an interview with Staff #15 (Chief Nursing Officer), she stated "all the complaints were accidentally shredded or misplaced by a Volunteer".

When asked why a Volunteer would have access to the patient complaints, Staff #15 stated that the Patient Advocate was also responsible for the Volunteers, and that the Volunteers were in and out of the office all the time.

The facility Policy titled "Control of Records" dated 09/02/13, identifies the "protection", "storage", "retrieval", and "disposition" of complaints and grievances as the responsibility of the Patient Advocate and documents that the records are to be stored in the Patient Advocate's Office (PAO) for a period of eight (8) years.

Due to the absence of a Patient Advocate or oversight of the PAO, the facility lacked a means to maintain the privacy and protection of the complaints / grievances from the Volunteers.
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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on Medical Record review, document review, and interview, the facility failed to reassess a patient in restraints to determine if the patient's behavior which was no longer a threat to self, staff members, or others, warranted the continued use of restraints. This was evident in one (1) of four (4) Patient Records reviewed with restraints.

The facility's failure resulted in a patient remaining in wrist restraints while asleep.

Findings:

Review of the Medical Record (MR) for Patient O documented the patient was admitted on [DATE] at 4:39PM for an overdose of Opiates. At 5:20PM the patient became agitated requiring the emergent use of Four (4) Point Violent Restraints. A Physician's Order was placed at 6:05PM.

On 08/06/15, a review of patient O's Medical Record revealed that at 7:36PM the patient's lower extremity restraints were removed because the patient was sleeping. The patient was kept in bilateral wrist restraints until a Nursing Note documented removal of the bilateral wrist restraints at 11:30PM, approximately 4 hours later. There was no new order obtained for the change in restraints.

A review of the patient Behavioral Health Services "Observation Record" documented the patient asleep from 8:00PM until 11:30PM, 3 1/2 hours. There was no documented reassessment of the patient's behavior to support the need for the patient's continued use of wrist restraints.

The "untitled" policy dated September 2012 which addresses restraints/seclusion stated under "Discontinuation of Restraint/Seclusion" that whenever the patient meets the behavioral criteria for discontinuation of the restraint/seclusion, the restraint is removed....."

These findings were confirmed by Staff #6 in the presence of Staff #16.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on Medical Record review, document review, and interview, the facility failed to: a) ensure timely orders and face to face interviews for a patient in restraints, and b) ensure accurate documentation of a patient placed in restraints. This was evident in three (3) of four (4) Patient Records reviewed with restraints.

The facility's failure to follow facility Policy and Procedure and correctly document restraints places all patients placed in Four (4) Point Violent Restraints at risk for harm.

Findings:

a) Review of the medical record documented that Patient M was admitted on [DATE] at 7:33PM for an overdose. As per the facility Security Log, at 8:20PM the patient was "verbally abusive intoxicated", "the decision was made to 4 (Four) Point patient" and "Patient was 4 (Four) Pointed".

No restraint documentation was found in the patient's Medical Record until a Nursing Note at 10:47PM documented restraints discontinued. The subsequent Nursing Note at 10:48PM documented "7:40PM Restraint Violent. Restraint type 4 (Four) Point mechanical bilateral wrist and ankle".

There was no explanation for the failure to document the use of 4 point restraints until approximately 3 hours later. There was no Observation Record found for the restraints.

A Physician's Assessment was documented at 8:16PM, but no Physician's Order for the restraint was noted in the Medical Record until 10:30PM.

These findings were confirmed with Staff #16 at the time of record review.

Review of the facility policy that is "untitled" dated September 2012 which addresses restraint/seclusion directs "upon arrival, and following the assessment, the physician shall write an order for mechanical restraint".

b) Review of the facility Security Log dated 08/03/15 at 7:13PM documents that Patient N was observed outside the hospital banging on the window. The patient came into the hospital agitated and the patient was "put in 4 (Four) Point Restraints as per Doctor's Orders". Review of the medical record documents that the patient then was admitted on [DATE] at 7:29PM for a fall with right leg pain.

A Physician's Order for the restraints was noted in the Medical Record at 7:31PM. However, there was no documentation of the patient in the Four (4) Point Restraints, and no Observation Record was found.

These findings were confirmed with Staff #16 at the time of record review.

Review of the facility policy that is "untitled" dated September 2012 which addresses restraint/seclusion, directs that the nursing staff shall assess every 15 minutes thereafter and record on the Behavioral Health Assessment and Monitoring form.

Review of the medical record for Patient X documented that the patient was admitted on [DATE] at 5:02PM with a chief complaint of vomiting and weakness secondary to drug abuse.

A Four (4) Point mechanical bilateral wrist and ankle restraint was ordered along with 1:1 observation for this patient on 07/25/15 at 9:30PM and the order documented that the restraint duration is four (4) hours (before a reassessment and new order needs to be written).

At 9:31PM on 07/25/15, the Nurse's Progress Note documents that the Dr Heavy had to be called (manpower) and that a Restraint Violent / Self-Destructive Flow Sheet was initiated on at 9:31PM. The Note further documents that the patient was on continuous 1:1 observation and that he was with Four (4) Point mechanical bilateral wrist and ankle restraints.

A Nurse's Note by the same Nurse on 07/25/15 at 9:32PM documents that the restraints were Two (2) Point canvas and applied as per Physician's Order and in accordance with hospital Policy.

There is no evidence of any Orders to renew the Four (4) Point Restraints or for changing the Order to Two (2) Point Restraints.
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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
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Based on document review and interview, the facility failed to ensure that staff had accurate knowledge of the requirements for a patient placed in violent restraints.

The facility's failure to ensure that staff understands the facility requirements for placement of violent restraints places all patients placed in Four (4) Point Violent Restraints at risk for harm.

Findings:

In an interview on 08/06/15 at 1:30PM with the Emergency Department (ED) RN, Staff #18, when asked what facility requirements are for when a Physician Face-to-Face is required for a patient in violent restraints, replied "within an hour".

In an interview on 08/06/15 at 1:35PM with Emergency Department (ED) RN Manager, Staff #16, when asked what facility requirements are for when a Physician Face-to-Face is required for a patient in violent restraints, replied "within fifteen (15) minutes".

In an interview on 08/06/15 at 1:40PM with the Emergency Department (ED) RN, Staff #19, when asked what facility requirements are for when a Physician Face-to-Face is required for a patient in violent restraints, she replied "within fifteen (15) minutes".

Review of the facility's "untitled " policy dated September 2012 which addresses restraint and seclusion documented "Each face-to-face evaluation and reevaluation of the patient is to be performed by the physician within 30 minutes of the restraint application".

None of the ED staff knew the facility Policy requirements for the Physician Face-to-Face when interviewed.
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VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
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Based on observations, document review and interview, the facility failed to ensure that the facility's staff followed Infection Control Safety Measures in accordance with the acceptable Standards of Infection Control Practices.

The failure to ensure that staff adhere to acceptable Standards of Practice for Infection Control, places patients at risk for exposure to infectious diseases.

Findings:

On 08/05/15 at 11:15AM Staff #10 was observed to walk into Room 261 without the proper PPE (Personal Protective Equipment) on 2 Central, without looking at any of the signage outside of the patient's room to assess the call bell malfunction.

The staff member was observed going into the room and making physical contact with the curtain by the patient and with the wall behind the patient in order to check the call bell.

Outside of the room was signage which indicated that in order to enter this room, you need to wear gloves if you touch anything. There is also a large red STOP sign on the wall.

A review of the Job Description for Staff #10, titled Electrician in the Department of Engineering, documents that the employee responds to Nurse Call Requests and therefore, will be in patient rooms as part of his role.

Staff #10's Medical Center Policy and Procedure and Safety Related Performance Standards documents that the employee should "support and comply with all hospital and departmental Policies and Procedures, and attends all mandatory in-services, continuing education ...".

A review of Staff #10's Personnel File revealed that the employee has been with the facility since 11/12/01 and had completed his "Introduction to Infection Control" on 12/08/14 and had a passing grade.

An interview with Staff #12, (Nurse Manager on 2 Central), on 08/05/15 at 11:30AM, concurred that Staff #10 should have been wearing the proper PPE since he had contact with the patient's environment and the patient was confirmed to have Clostridium Difficile (C-Diff), which is an infectious disease that is transmitted when coming in contact with, or when touching surfaces which are contaminated with the organism.

The facility's Policy titled "Clostridium Difficile" documents that Contact Precautions must be maintained. Workers must use gloves for touching anything in the environment and also a gown if there is any contact with the patient. Visitors should be instructed to wear PPE as dictated by the level of interaction with the environment and the patient.

The Policy titled "Isolation Precautions" for "All Personnel" dated 03/26/12 under Contact Precautions documents that a gown and gloves should be worn for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. The purpose is to contain pathogens, especially those that have been implicated in transmission through environmental contamination.
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VIOLATION: DOCUMENTATION OF EVALUATIONS Tag No: A0811
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on Medical Record review and document review, the Care Management Staff did not actively engage a patient in the development of his Discharge Plan. This was evident in one (1) of five (5) Medical Records.

This failure may potentially complicate the patient's recovery and/or lead to a readmission.

Findings:

Review of Patient C's Medical Record identified the following information: This [AGE]-year-old male, with a past medical history of Schizophrenia since childhood, (MDS) dated [DATE] after being involved in a Motor Vehicle Accident (MVA).

Care Management Notes in the Clinical Notes Report of the Medical Record from 07/08/15 through discharge on 07/21/15 did not reflect that Patient C was included in the development of his Discharge Plan. Care Management documentation did not state the patient was informed, updated, or asked about Discharge Plans or arrangements.

No documentation, including notification to the patient about his Discharge Plans, was found until the day of discharge on 07/21/15.

The facility's Policy and Procedure titled, "Discharge Planning", last approved on 06/04/15 stated, "... The Discharge Plan will be regularly and systematically reviewed by the patient, the Care Manager and or Social Worker and the Interdisciplinary Team. The Discharge Plan shall be periodically updated to reflect the evolving needs and desires of the patient. The patient's progress and any changes in the plan will be noted in the Clinical Notes Section of the Electronic Medical Record."
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VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on Medical Record review and document review, the staff did not refer the patient to an Outpatient Psychiatric Service for follow-up care. This was evident in one (1) of five (5) Medical Records reviewed.

This failure may potentially complicate the patient's recovery and/or lead to a readmission.

Findings:

Review of Patient C's Medical Record identified the following information: This [AGE]-year-old male, with a past medical history of Schizophrenia since childhood, (MDS) dated [DATE] after being involved in a Motor Vehicle Accident (MVA).

Review of the Initial Physician's History and Physical dated 07/07/15 states, "Patient is not currently compliant with any psych medications". There was no further documentation for psychiatric follow-up during the hospitalization found in the record.

The Transfer Summary dated 07/13/15 stated, "The patient was also evaluated by Psychiatry, ruling out psychotic events. The patient was placed on Zyprexa and was followed by Psychiatrist. The patient needs close observation to be compliant with physical therapy and medications. It is reported that the patient is homeless and non-compliant with housing. Therefore, Dr. ... recommended to place the patient in subacute rehab ... the patient will be placed in a subacute rehab to get compliant with physical therapy and medications ... the patient will be followed up by Neurosurgery within two (2) weeks, and by Trauma Surgeon within ten (10) days. The patient will also be followed by Psychiatrist as needed."

A Care Management Note dated 07/16/15 stated, "Patient has no available sub-acute bed offers" and "no authorization given by Insurance ... " for sub-acute rehab. In addition, Physical Therapy (PT) Services were discontinued on 07/19/15 documenting, "Patient is cleared from PT since patient is functionally independent."

Since patient no longer qualified to be discharged to a subacute rehab, arrangements were made for patient to be discharged to a shelter. Patient Discharge Plan / Instructions dated and signed by patient on 07/21/15 refer patient to medical follow-up with Neurosurgery and Ortho-Trauma Surgeon, but no referral for Outpatient Psychiatric follow-up is listed on Patient C's Discharge Instructions.

The facility's Policy and Procedure titled, "Discharge Planning", last approved 06/04/15 stated, "When determining post hospital care services, available resources are determined by multiple factors including, but not limited to Insurance Plan benefits, level of care determination by Physician and available resources at time of discharge."