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COMMUNITY MEDICAL CENTER 99 RT 37 WEST TOMS RIVER, NJ 08755 July 2, 2020
VIOLATION: DISCHARGE PLANNING- TRANSMISSION INFORMATION Tag No: A0813
Based on staff interview and review of one (1) out of one (1) medical record (#1), it was determined that the facility failed to ensure patients receive appropriate post-hospital care by arranging, as applicable, transfer to appropriate facilities.

Findings include:

1. On 7/1/20 at 11:45 AM, Patient #1's medical record was reviewed with Staff #1 and the following was revealed:

a. Patient #1 arrived at the Emergency Department (ED) on 3/31/20 at 5:53 PM via Emergency Medical Services (EMS).

(i) The Nursing Triage Note stated " ... from [facility name], for +(positive) BL (bilateral) DVT (Deep Vein Thrombosis) ... call to [facility name]."

(ii) The ED Physician Note states, " ... Patient arrived to ED via EMS from assisted living. ..."

b. The patient was admitted to the Rapid Decision Unit (RDU) from the ED on 3/31/20.

(i) On 4/1/20 at 12:05 PM, the "Ongoing Discharge Planning Note" stated "cm (case manager) spoke to patient at bedside and is from [facility name]. States does use a walker. Will return upon discharge."

(ii) On 4/1/20 at 1:51 PM, the "Ongoing Discharge Planning Note stated, "cm called and spoke to [facility name], they would like care plan/medication list and any new medications ... Nurse ... made aware."

c. The medical record contained two (2) documents from the facility that was referenced in the above nursing and case management notes that included the facility name, indicating it was a "Class C Board & Care Residence," the facility address, the patient's personal medical history form, patient identifying information, emergency contact information and medication list.

2. At 12:10 PM, Staff #1 explained that the patient was discharged via facility contracted transport staff on 4/1/20 at 9:00 PM to the address documented on the patients face sheet, which was different from the address of the facility that was documented as where the patient arrived from.

3. The above findings were confirmed by Staff #1 and Staff #3 on 7/2/20 at 11:38 AM.