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.

TEXAS HEALTH PRESBYTERIAN HOSPITAL ROCKWALL 3150 HORIZON ROAD ROCKWALL, TX 75032 June 9, 2015
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on interview and record review the facility failed to ensure there was documentation to show accurate dates of when complaints and grievances were received, thoroughly investigated and timely follow-up notification to grievances. This deficient practice was found in grievances during the timeframe between January 2014-June 2015.
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of the facility complaint and grievance log from January 2014 to June 2015 revealed no documented evidence of date of receipt, investigation completion date or follow-up letters being sent out.
The following was found in individual reports:
04/14/2015 (date of incident)
"During a follow-up call patient reports she would not send her dog to our hospital. She reports she was treated badly while here. She listed complaints of not getting her pain medication when needed, being sent home with no pain medication except tramadol which wasn't effective, was made to wear TED hose that were to small causing a grey line in her post leg where hose rolled her skin, was told no when asking for pain medication by person answering call light, was told when she complained she was cold that the air conditioning was turned as warm as it could go, pt was not offered a warm blanket, her daughter went to desk to get warm blanket for her. Pt. states the whole floor was horrible". Pt. reports she like "(staff name) didn't listen to her" She was visited by Nursing Director but felt it was too late, "damage had been done". She reports that "everyone was as nasty as could be". She said the last day and were tolerable. Pt went on at length with her concerns. I apologized to her for her experience and explained that we could not change how her experience was but would do our best to improve, I thanked her for sharing her concerns and assured her we would f/u."
Review of complaint information revealed the complaint was received from a discharge call on 04/15/2015.
Review of the Risk Manager Review dated (04/10/2015) revealed the investigation was complete and no further action was required.
Underneath other actions taken the following was documented:
Follow-up phone call with patient was reiterated not feeling listened to and slow response. Staff apologized regarding experience. Patient stated she met with manager and care was better prior to discharge. Patient states feeling better and no other issue.
There was no documentation if any of the patient concerns made after discharge were investigated prior to the follow-up call. There was no evidence a written letter was sent for this grievance as per facility policy
During an interview on 06/09/2015 after 8:30 a.m., Staff #3 reported the 04/10/2015 was written in error. She confirmed there was no documented investigation of the incident.

08/06/2014 (date of incident)
Patient grievance information obtained via Press Ganey survey (number of complaint given)
Patient Wrote: Staff at (name of hospital) should not discuss "Obamacare" with patients. Very ugly comments that were not asked for. The LAW is called the Affordable Health Care Act ...NOT OBAMACARE. I don' t care what side of the fence you are on regarding the new health care law ....you should not discuss it with patients. A doctor and Case Manager both let their feelings be known.
09/24/2014(date complaint received)
09/29/2014 there was documentation the Case Management department was involved. Case management reviewed the incident on 09/29/2014. The plan of action was they tried to contact the patient 2 times to discuss. Left voicemail. Discussed with all staff the importance of courtesy and not stereotyping issues.
According to the form underneath the Risk Manager Review section the complaint was reviewed on 08/15/2014 (over a month prior to receipt) investigation and was classified as complete and no further action required. There was documentation they spoke to the patient regarding concerns. Informed patient that state (meaning staff) were made aware how to discuss insurance and affordable care act, patient had no further issues.
There was no documentation of the patient being sent a written response within 7 days of making the grievance.

07/30/2014 (date of incident)
Patient Grievance Information received via Press Ganey Survey (number of incident recorded).
Patient wrote" when I left the hospital I went to rehab at (name of place). However I had a fairly severe case of sepsis. I had passed out prior to release but was released anyway. I got sicker while at (name of rehab). But they tested me proactive measure had if I had not fallen and injuryed my hip I would have died from infection."
Date of receipt was documented as 09/30/2014.
According to the form on 08/04/2014 the manager reviewed the grievance and on 08/05/2014 the risk manager reviewed the grievance (over a month before it was received). The investigation was complete and no further action required. Both responses were both the complaint receipt date.
There was no documentation of the patient being sent a written response within 7 days of making the grievance. There was no documentation of written 30 day notice being provided.

07/08/2014 (date of incident)
Information received via Press Ganey Survey (number of incident recorded). Patient wrote: 'Getting discharged was not very good. Husband had to see what was going on. Nurses forgot to remove IV needle. Nurses seem to disappear.'
09/05/2014(date complaint received)
09/09/2014 (4 days later) there was documentation the patient was called. They talked about the discharge process and reviewed concerns. Apologized for experience not being good. There was documentation there was no further action required.
There was no documentation in the report of a plan of action taken or if any staff training was done as a result. The facility failed to show evidence the allegation was investigated and a letter was sent as stated by their policy for this grievance.


05/04/2014 (date of incident)
A patient letter started out as follows
"I was a patient at (name of hospital) May 1, 2014 and had a knee replacement operation. Several mistakes were made with my care and dismissal; things that has made my recovery difficult."
The patient outlined a list of concerns which included the process of her placement at another facility, physician instruction to the receiving facility, TED hose not being placed on, medication concerns and therapy services.
At the bottom of two page letter the following was documented:
"I would very much like a response and explanation to this letter on what went wrong and that someone is held responsible and changes made. If I do not hear back I will sending a report to the appropriate authorities."
According to documentation the letter was received on 07/03/2014. The patient received 2 response letters one on 07/03/2014 and another on 07/16/2014. There was no documentation of a description of the steps taken to investigate the grievance. There was no documentation of a completion of the investigation.

On 01/21/2015 another two page letter from the same patient was sent to the facility again. The letter outlined the same issues mentioned in the 07/03/2014 letter.
On 02/23/2015 (thirteen days later) the following response letter was sent:
"It is unfortunate that you did not feel that you had the quality of care experience we strive to achieve. Your case has again been reviewed for a second time for quality of care issues and none were identified. We do wish you good health and hope things improve with time."
The facility failed to send response letters in a timely manner. They failed to provide documentation of a description of the steps taken to investigate the grievance. There was no documentation of a completion of the investigation.

During an interview on 06/09/2015 after 8:30 a.m., Staff #3 confirmed not knowing when the complaints were received because of all the conflicting dates. She confirmed the late response letters and the missing information. Staff #3 reported she was currently over Risk management, quality and infection control.

Review of a facility policy named "COMPLAINT/GRIEVANCE: MANAGEMENT OF PATIENT AND FAMILY" dated April 2013 revealed the following:
III.DEFINITIONS
2. Complaint- An issue is considered resolved by Staff Present, as herein defined, when the patient is satisfied with actions taken on his /her behalf, or the nature of the complaint does not meet the definition of a grievance.
Post-discharge verbal communication regarding patient care that would routinely have been handled by Staff Present if the communication that occurred during the stay, are not required to be defined as a grievance.
3. Grievance - A formal or informal written (written communication is always considered a grievance) or verbal complaint (when a verbal complain about patient care is not resolved at the time of the complaint by Staff Present) by a patient or patient's representative, regarding any of the following:
1. The patient's care,
2. Abuse or neglect,
3. Issues related to the organization's compliance with the CMS Hospital Conditions of Participation (COP) or
4. A Medicare beneficiary billing complaint related to rights and limitations provide 42 CRR489
When the patient care complaint cannot be resolved at the time of the complaint by Staff Present, is postponed for later resolution, it referred to another staff member for later resolution, requires investigation, and /or requires further actions for resolution then the complaint is a grievance.

5. Providing the initial response to the patient complaint
Response within 7 days. The Hospital shall review, investigate and resolve each patient's grievance within a reasonable time frame. Grievances that are not complicated should be resolved and the Hospital will send a written letter to the patient or patient's representative within seven (7) days. See Section 5.5 below for the contents of the letter, If the Hospital is unable to resolve the grievance within seven (7) days from receipt, the Hospital will send a written acknowledgment within seven (7) days of the time of the grievance. The acknowledgment will state that he/she will receive written follow-up upon completion of the investigation, including an estimate of the time of the final response.
7. Providing follow-up responses to grievances. For patient grievances, the Hospital will see that a letter is sent to the person who reported the grievance within thirty (30) days of the date of the time of the grievance and include the following information:
a. Name of the Hospital contact person,
b. A description of the steps taken to investigate the grievance,
c. Date of completion of the investigation. (If the investigation has not been completed within thirty days (e.g.it is referred to Litigation Services for review}, inform the person that the investigation is ongoing and they will be notified when it is completed}: and
d. A summary of the results of the grievance process.
The Grievance Coordinator may contact Legal Services for assistance in responding to the patient.
VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES Tag No: A0120
Based on interview and record review the facility failed to ensure there was documentation to show accurate dates of when complaints and grievances were received, thoroughly investigated and timely follow-up notification to grievances. This deficient practice was found during the timeframe between January 2014-June 2015.
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of the facility complaint and grievance log from January 2014 to June 2015 revealed no documented evidence of date of receipt, investigation completion date or follow-up letters being sent out.
The following was found in individual reports:
04/14/2015 (date of incident)
"During a follow-up call patient reports she would not send her dog to our hospital. She reports she was treated badly while here. She listed complaints of not getting her pain medication when needed, being sent home with no pain medication except tramadol which wasn't effective, was made to wear TED hose that were to small causing a grey line in her post leg where hose rolled her skin, was told no when asking for pain medication by person answering call light, was told when she complained she was cold that the air conditioning was turned as warm as it could go, pt was not offered a warm blanket, her daughter went to desk to get warm blanket for her. Pt. states the whole floor was horrible". Pt. reports she like "(staff name) didn't listen to her her" She was visited by Nursing Director but felt it was too late, "damage had been done". She reports that "everyone was as nasty as could be". She said the last day and were tolerable. Pt went on at length with her concerns. I apologized to her for her experience and explained that we could not change how her experience was but would do our best to improve, I thanked her for her sharing her concerns and assured her we would f/u."
Review of complaint information revealed the complaint was received from a discharge call on 04/15/2015.
Review of the Risk Manager Review dated (04/10/2015) revealed the investigation was complete and no further action was required.
Underneath other actions taken the following was documented:
Follow-up phone call with patient was reiterated not feeling listened to and slow response. Staff apologized regarding experience. Patient stated she met with manager and care was better prior to discharge. Patient states feeling better and no other issue.
There was no documentation if any of the patient concerns made after discharge were investigated prior to the follow-up call. There was no evidence a written letter was sent for this grievance as per facility policy
During an interview on 06/09/2015 after 8:30 a.m., Staff #3 reported the 04/10/2015 was written in error. She confirmed there was no documented investigation of the incident.

08/06/2014 (date of incident)
Patient grievance information obtained via Press Ganey survey (number of complaint given)
Patient Wrote: Staff at (name of hospital) should not discuss "Obamacare" with patients. Very ugly comments that were not asked for. The LAW is called the Affordable Health Care Act ...NOT OBAMACARE. I don ' t care what side of the fence you are on regarding the new health care law ....you should not discuss it with patients. A doctor and Case Manager both let their feelings be known.
09/24/2014(date complaint received)
09/29/2014 there was documentation the Case Management department was involved. Case management reviewed the incident on 09/29/2014. The plan of action was they tried to contact the patient 2 times to discuss. Left voicemail. Discussed with all staff the importance of courtesy and not stereotyping issues.
According to the form underneath the Risk Manager Review section the complaint was reviewed on 08/15/2014 (over a month prior to receipt) investigation and was classified as complete and no further action required. There was documentation they spoke to the patient regarding concerns. Informed patient that state (meaning staff) were made aware how to discuss insurance and affordable care act, patient had no further issues.
There was no documentation of the patient being sent a written response within 7 days of making the grievance.

07/30/2014 (date of incident)
Patient Grievance Information received via Press Ganey Survey (number of incident recorded).
Patient wrote" when I left the hospital I went to rehab at (name of place). However I had a fairly severe case of sepsis. I had passed out prior to release but was released anyway. I got sicker while at (name of rehab). But they tested me proactive measure had if I had not fallen and injuryed my hip I would have died from infection."
Date of receipt was documented as 09/30/2014.
According to the form on 08/04/2014 the manager reviewed the grievance and on 08/05/2014 the risk manager reviewed the grievance (over a month before it was received). The investigation was complete and no further action required. Both responses were both the complaint receipt date.
There was no documentation of the patient being sent a written response within 7 days of making the grievance. There was no documentation of written 30 day notice being provided.

07/08/2014 (date of incident)
Information received via Press Ganey Survey (number of incident recorded). Patient wrote: 'Getting discharged was not very good. Husband had to see what was going on. Nurses forgot to remove IV needle. Nurses seem to disappear.'
09/05/2014(date complaint received)
09/09/2014 (4 days later) there was documentation the patient was called. They talked about the discharge process and reviewed concerns. Apologized for experience not being good. There was documentation there was no further action required.
There was no documentation in the report of a plan of action taken or if any staff training was done as a result. The facility failed to show evidence the allegation was investigated and a letter was sent as stated by their policy for this grievance.


05/04/2014 (date of incident)
A patient letter started out as follows
"I was a patient at (name of hospital) May 1, 2014 and had a knee replacement operation. Several mistakes were made with my care and dismissal; things that has made my recovery difficult."
The patient outlined a list of concerns which included the process of her placement at another facility, physician instruction to the receiving facility, TED hose not being placed on, medication concerns and therapy services.
At the bottom of two page letter the following was documented:
"I would very much like a response and explanation to this letter on what went wrong and that someone is held responsible and changes made. If I do not hear back I will sending a report to the appropriate authorities."
According to documentation the letter was received on 07/03/2014. The patient received 2 response letters one on 07/03/2014 and another on 07/16/2014. There was no documentation of a description of the steps taken to investigate the grievance. There was no documentation of a completion of the investigation.

On 01/21/2015 another two page letter from the same patient was sent to the facility again. The letter outlined the same issues mentioned in the 07/03/2014 letter.
On 02/23/2015 (thirteen days later) the following response letter was sent:
"It is unfortunate that you did not feel that you had the quality of care experience we strive to achieve. Your case has again been reviewed for a second time for quality of care issues and none were identified. We do wish you good health and hope things improve with time."
The facility failed to send response letters in a timely manner. They failed to provide documentation of a description of the steps taken to investigate the grievance. There was no documentation of a completion of the investigation.

During an interview on 06/09/2015 after 8:30 a.m., Staff #3 confirmed not knowing when the complaints were received because of all the conflicting dates. She confirmed the late response letters and the missing information. Staff #3 reported she was currently over Risk management, quality and infection control.

Review of a facility policy named "COMPLAINT/GRIEVANCE: MANAGEMENT OF PATIENT AND FAMILY" dated April 2013 revealed the following:
III.DEFINITIONS
2. Complaint- An issue is considered resolved by Staff Present, as herein defined, when the patient is satisfied with actions taken on his /her behalf, or the nature of the complaint does not meet the definition of a grievance.
Post-discharge verbal communication regarding patient care that would routinely have been handled by Staff Present if the communication that occurred during the stay, are not required to be defined as a grievance.
3. Grievance - A formal or informal written (written communication is always considered a grievance) or verbal complaint (when a verbal complain about patient care is not resolved at the time of the complaint by Staff Present) by a patient or patient's representative, regarding any of the following:
1. The patient's care,
2. Abuse or neglect,
3. Issues related to the organization's compliance with the CMS Hospital Conditions of Participation (COP) or
4. A Medicare beneficiary billing complaint related to rights and limitations provide 42 CRR489
When the patient care complaint cannot be resolved at the time of the complaint by Staff Present, is postponed for later resolution, it referred to another staff member for later resolution, requires investigation, and /or requires further actions for resolution then the complaint is a grievance.

5. Providing the initial response to the patient complaint
Response within 7 days. The Hospital shall review, investigate and resolve each patient's grievance within a reasonable time frame. Grievances that are not complicated should be resolved and the Hospital will send a written letter to the patient or patient's representative within seven (7) days. See Section 5.5 below for the contents of the letter, If the Hospital is unable to resolve the grievance within seven (7) days from receipt, the Hospital will send a written acknowledgment within seven (7) days of the time of the grievance. The acknowledgment will state that he/she will receive written follow-up upon completion of the investigation, including an estimate of the time of the final response.
7. Providing follow-up responses to grievances. For patient grievances, the Hospital will see that a letter is sent to the person who reported the grievance within thirty (30) days of the date of the time of the grievance and include the following information:
a. Name of the Hospital contact person,
b. A description of the steps taken to investigate the grievance,
c. Date of completion of the investigation. (If the investigation has not been completed within thirty days (e.g.it is referred to Litigation Services for review}, inform the person that the investigation is ongoing and they will be notified when it is completed}: and
d. A summary of the results of the grievance process.
The Grievance Coordinator may contact Legal Services for assistance in responding to the patient.
VIOLATION: CONTENT OF RECORD - INFORMED CONSENT Tag No: A0466
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review the facility failed to ensure patient choice consents for rehab placement were accurately completed in 4 of 4 Patients (#s' 2, 3, 4, and 5).
This deficient practice had the likelihood to cause harm in all patients being transferred for rehab services.
Findings include:

During an interview on 06/08/2015 after 10:00 a.m. Patient #2 reported complaints about insurance approval problems with places for his rehab.
Review of the clinical record on Patient #2 revealed he was a [AGE] year old male admitted on [DATE] with a chief complaint of shortness of breath.
Review of a "Patient Choice Form" (used to show patient choice and consent to rehab facilities) revealed the section for documenting the insurance provider was left blank.
At the bottom of the form was the following:
Please indicate whether or not you will allow placement with the first responder or previous provider. Once you make your selection, the Case Management Department representative will make the necessary arrangements for you.
I agree with placement recommended by physician/insurance _____Yes ________No (section left blank)
I will allow placement with existing provider___Yes _______No (section left blank)
I choose _________________ (name of facility written in)
Patient #2 signed off on the form and dated 06/05/2015 and a hospital representative signed and dated the form 06/15/2015 (wrong date).

During an interview on 06/08/2015 after 10:00 a.m., Patient #3 reported she had hip surgery during her stay at the hospital. Patient #3 reported she was going to a rehab and her daughter had chosen the place.
During an observation on 06/08/2015 at 12:35 p.m., Patient #3 was observed to be discharged from the hospital.
Review of the clinical record on Patient #3 revealed she was a [AGE] year old female admitted on [DATE].
Review of a "Patient Choice Form" revealed the section for documenting the insurance provider was left blank. At the bottom of the form was the following:
Please indicate whether or not you will allow placement with the first responder or previous provider. Once you make your selection, the Case Management Department representative will make the necessary arrangements for you.
I agree with placement recommended by physician/insurance _____Yes ________No (section left blank)
I will allow placement with existing provider___Yes _______No (yes checked in this section)
I choose _________________ (name of facility written in)
Patient or Patient Representative ____________________. The following documentation was written in that section "Verbal release from Pt she was walking c PT" This section was dated 06/08/2015. A hospital representative signed the form and dated it 06/08/2015. There was no documentation that staff went back had the form signed by Patient #3.

Review of a clinical record on Patient #5 revealed she was a [AGE] year old female admitted on [DATE]. During the stay Patient #5 had a right total knee arthroplasty and was discharged on [DATE].
Review of case management notes dated 05/02/2014 revealed Patient #5 was going to a rehab (name of facility documented) and the patient and son approved.
Review of a "Patient Choice Form" signed off 05/02/2014 revealed the section for documenting the insurance provider was left blank.
At the bottom of the form was the following:
Please indicate whether or not you will allow placement with the first responder or previous provider. Once you make your selection, the Case Management Department representative will make the necessary arrangements for you.
I agree with placement recommended by physician/insurance _____Yes ________No (section left blank)
I will allow placement with existing provider___Yes _______No (section left blank)
I choose _________________. The name of the facility was written in, but it was not the rehab facililty listed in the case management notes.


Review of the clinical record on Patient #4 revealed she was a [AGE] year old female admitted on [DATE]. According to a discharge summary Patient #4 had a total joint replacement (knee) and was discharged on [DATE] to rehab.
Review of complaint and grievance information revealed Patient #4 sent in two page complaint outlining her grievance during her hospital stay from 05/01-04/2014. One of the grievance listed was on 05/02/2014 and there was documentation a lady approached Patient #4's husband (a [AGE] year old man with memory problems). She asked him the place he wanted me transferred. He was completely surprised and said he didn't know, and he understood that it was up to the doctor. She kept insisting that she had to know immediately because the weekend was coming and Patient #4 had to leave the hospital. The only place her husband could think of was (name listed) because it was close to their house. The staff member said great and left ... ...
Patient #4 sent the grievance letter in July 2014 and again in January 2015.
Review of case management notes dated 05/02/2014 at 11:50 a.m. revealed they met with the patient and spouse to discuss discharge planning. According to documentation Patient #4 stated she wanted to go to rehab and they would like a referral to (rehab name was listed).
Review of a "Patient Choice Form" dated 05/02/2014 and not timed revealed at the bottom of the form the following:
Please indicate whether or not you will allow placement with the first responder or previous provider. Once you make your selection, the Case Management Department representative will make the necessary arrangements for you.
I agree with placement recommended by physician/insurance _____Yes ________No (section left blank)
I will allow placement with existing provider___Yes _______No (section left blank)
I choose _________________ (name of facility written in)
Patient or Patient Representative ____________________. Two staff had signed the consent form in this area. Above their signatures there was documentation they received a telephone consent from Patient #4s' husband. There was no documentation of the reason explaining whey they had to get a telephone consent from the husband. There was no documentation of staff attempting to obtain a signature from the husband after taking a phone consent.

During an interview on 06/08/2015 after 11:05 a.m. and 06/09/2015 after 9:00 a.m.,Staff #5 confirmed the condition of the forms. Staff #5 reported Patient #4 did not want to deal with it and wanted her husband to sign the form. Staff #5 confirmed there was no documentation of this in the record.



Review of a facility policy named "INFORMED CONSENT FOR MEDICAL AND SURGICAL PROCEDURES" dated July 2007 revealed the following:

I. If telephone permission is obtained from the legally responsible person, two (2) nurses must hear the telephone consent and both must sign as witnesses. The person giving permission will be requested to give permission (via wire or in person) as soon as possible ....
J. The patient will sign the consent unless unable to do so because of physical, mental, emotional or legal compromise. In cases where the legally responsible person signs in lieu of the patient, the reason necessitating this action must be documented on the consent form.
2. If the form is signed by a person other than the patient, the reason and the relationship to the patient must be indicated.
3. The following will determine legal signatures of patient or other legally responsible person:
k.Monitored (person) consent: Acceptable it is impossible to obtain signatures. There must be two (2) witnesses for phone consent to be valid. Request that a follow-up telegram or letter consent be sent to medical records department.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure complete discharge physician orders were sent to the receiving facility and failed to ensure discharge information was kept in the clinical record. They failed to ensure all discharge paperwork was complete in 1 of 1 patients (Patient #4).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of the clinical record on Patient #4 revealed she was a [AGE] year old female admitted on [DATE]. According to a discharge summary Patient #4 had a total joint replacement (knee) and was discharged on [DATE] to rehab.

Review of complaint and grievance information revealed Patient #4 sent in two page complaint outlining her grievance during her stay from 05/01-04/2014. One of the grievance listed was on 05/02/2014, a lady approached her husband ( a [AGE] year old man with memory problems). She asked him the place he wanted me transferred. He was completely surprised and said he didn't know, and he understood that it was up to the doctor. She kept insisting that she had to know immediately because the weekend was coming and Patient #4 had to leave the hospital. The only place her husband could think of was (name listed) because it was close to their house. The staff member said great and left ... ...
Patient #4 wrote that her doctor was not able to give any instructions for her care and no care instructions were given as to what her care should consist of. He did not have privileges there .....
Patient #4 wrote the place was absolutely not equipped to care for her type of operation, especially 3 days after surgery with only 1 day of therapy.
Patient #4 sent the grievance letter in July 2014 and again in January 2015.
Review of case management notes dated 05/02/2014 at 11:50 a.m. revealed they met with the patient and spouse to discuss discharge planning. According to documentation the patient stated she wanted to go to rehab and they would like a referral to (rehab name was listed).
Review of case management notes dated 05/02/2014 at 11:50 a.m. revealed they met with the patient and spouse to discuss discharge planning. According to documentation Patient #4 stated she wanted to go to rehab and they would like a referral to (rehab name was listed).

Review of a "Patient Choice Form" dated 05/02/2014 and not timed revealed at the bottom of the form was the following:
Please indicate whether or not you will allow placement with the first responder or previous provider. Once you make your selection, the Case Management Department representative will make the necessary arrangements for you.
I agree with placement recommended by physician/insurance _____Yes ________No (section left blank)
I will allow placement with existing provider___Yes _______No (section left blank)
I choose _________________ (name of facility written in)
Patient or Patient Representative ____________________. Two staff had signed the consent form in this area. Above their signatures there was documentation they received a telephone consent from Patient #4s' husband. There was documentation of the reason explaining whey they had to get a telephone consent from the husband. There was no documentation of staff attempting to obtain a signature from the husband after taking a phone consent.

Review of Facility Transfer Orders dated 05/04/2014 at the hospital and at the receiving hospital revealed the physician orders were not complete with all treatments needed.

During an interview on 06/08/2015 after 11:05 a.m. and 06/09/2015 after 9:00 a.m.,Staff #5 confirmed the condition of the forms. Staff #5 reported Patient #4 did not want to deal with it and wanted her husband to sign the form. Staff #5 confirmed there was no documentation of this in the record. Staff #5 confirmed they got a copy of the transfer orders from the receiving facility and they were not the complete set.

Review of the facility policy named "DISCHARGE PROCESS" dated 9/2013 revealed the following:
C. Individual discharge instructions will be given to every patient or patient representative toprovide for the continuity of care and a smooth transition to their discharge environment.
E. Routine Discharge: Upon receipt of physician discharge order, the RN or LVN HUC will
4. Complete "Discharge instructions"form
a. Review with patient and/or family along with any prescriptions, equipment or other instructions requested by the physician.
b.Copy to be given to the patient.
c. Copy to be put with the chart.