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.

PEAK VIEW BEHAVIORAL HEALTH 7353 SISTERS GROVE COLORADO SPRINGS, CO 80923 April 11, 2018
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on interviews and record review, the facility failed to inform the patient's family member and power of attorney (POA) of the patient's transfer to a skilled nursing facility (SNF) prior to discharge in 1 of 7 discharged medical records reviewed (Patient #1).

Findings include:

Policy

The facility's policy Discharge and Continuing Care Planning read, the therapist/case manager is responsible for coordinating the discharge plan. Notice of discharge shall be provided to the individual, or the individual's legal representative, in a timely manner in advance of the discharge.

The facility's policy Aftercare/Discharge Plan read, the therapist/case manager addresses discharge planning with the family, when appropriate, and the patient during the family therapy session and conferences on an ongoing basis. This is documented throughout the course of treatment in the medical record, case management notes. Program staff reviews the plan upon discharge with the patient and/or family and obtains their signatures.

1. The facility failed to notify a patient's family member and POA prior to the patient's discharge and transfer to a skilled nursing facility (SNF).

a. An interview with Inpatient Clinical Director (Director) #5 was conducted on 4/10/18 at 2:06 p.m. According to Director #5, each patient's assigned therapist was responsible to collaborate on a discharge plan with the patient and their family. Once a confirmed placement to a SNF was received, it was expected the family would be notified of the date and time of discharge at least 24 hours prior to the discharge. Director #5 stated the notification should be documented in the patient's medical record.

b. Review of Patient #1's medical record revealed he was admitted to the facility from an assisted living facility (ALF) on 12/4/17. Patient #1 was placed on an Emergency Mental Illness (M-1) hold for increased aggression with staff and other residents at his ALF. According to the M-1 report and application, completed 12/4/17 at 2:53 p.m., Patient #1 was oriented only to self, was nonsensical, and unable to make safe decisions. Patient #1 remained in the facility until 1/4/18.

According to Physician #'2's discharge summary, written 1/4/18 at 2:53 p.m., Patient #1's condition improved after the addition of Keppra (an anti-seizure medication). Patient #1 was stabilized on his medication regimen and no longer required interventions for aggressive behavior. His cognitive functions were grossly intact and insight and judgement were fair.

On 12/20/17 at 9:18 a.m., Therapist #3 documented a voicemail had been left for Patient #1's POA and family member to inform them placement was not available within the local county, and the search would be expanded outside the county.

In a progress note, dated 12/28/17, Physician #2 documented under discharge plan Patient #1 had been accepted at a SNF in a city outside the county pending receipt of required documents. There was no documentation to show the POA of Patient #1 had been notified of the SNF placement.

Case Manager (CM) #1 documented in the medical record she updated the family member via phone on 12/28/17 at 9:10 a.m., 12/29/17 at 3:04 p.m., 1/1/18 at 9:14 a.m., 1/2/18 at 9:29 a.m., 1/3/18 at 1:32 p.m., and 1/4/18 at 10:00 a.m. (the day of discharge). However, none of the case management progress notes revealed the family or POA were notified of Patient #1's placement or the pending discharge date .

According to the nursing discharge note on 1/4/18 at 2:59 p.m., documented by Registered Nurse (RN) #4, discharge paperwork had been reviewed and signed by Patient #1. RN #4 wrote, Patient #1 was sent with his personal belongings and paperwork to the accepting SNF on 1/4/18 at 16:30 p.m. via transport arranged by the facility.

Review of nursing notes, case management notes, and therapist notes revealed no documentation the family member or the POA were notified of the date of discharge or final disposition of Patient #1 prior to the discharge as required by facility policy.

c. An interview with CM #1 was conducted 4/10/18 at 1:05 p.m. CM #1 stated she documented in a case manager progress note any conversations with families which included updates on discharge planning. CM #1 confirmed she did not notify Patient #1's family of the new SNF placement in her phone call updates with the family member. According CM #1, Therapist #3 planned to notify the POA since the SNF was not local. CM #1 stated there should have been documentation within the medical record to show when Patient #1's POA and family had been notified of the SNF placement, discharge date and time.

d. An interview with the medical director of the facility (Physician #2) was conducted on 4/10/18 at 4:05 p.m. Physician #2 stated the facility should notify patients' families as soon as an accepting SNF was found. She stated the expectation was for the case manager or therapist to document the notification with a note in the patient's medical record. According to Physician #2, Therapist #3 was specifically contracted to perform discharge planning for the geriatric patient population and required to document the plan in the medical record.

Physician #2 stated Therapist #3 was not available for interview during the survey.

e. Review of Therapist #3's contract for consulting senior services with the facility revealed Therapist #3 was expected to participate in treatment rounds, reports, tracking, and documentation.

f. An Interview with Chief Executive Officer (CEO) #6 was conducted on 4/11/18 at 7:48 a.m. CEO #6 stated it was not appropriate for the facility to fail to notify Patient #1's family of his discharge and transfer to the SNF. CEO #6 stated he was "surprised" Patient #1's family was not notified, but stated "if it wasn't documented, it didn't happen."