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Based on record review and interview, the hospital failed to ensure each patient received care in a safe setting as evidenced by failing to ensure patients were appropriately assessed prior to being transported by non-emergency personnel for 1 (#2) of 4 patients who's medical record was reviewed for discharge planning from a total sample of 5 patients. Findings:Review of Pre-Admission Screen dated 11/02/16 revealed patient #2 was a 54 year old male admitted to hospital (a) on 10/24/16 for possible stroke and was followed up with neuro with a CT scan on 10/24/16 and repeated on 10/26/16 with no indications of cranial bleeding. The patient was positive for cocaine on his drug screen. Patient #2 had a PEG tube placed during admission due to dysphagia.Review of patient #2's medical record revealed he had been admitted to Tri Parish Rehabilitation hospital on 11/07/16 with diagnoses of CVA with Right Hemiparesis, A-Fib, Dysphagia, Dysarthria, CHF, CAD, COPD, Obesity, History of Cocaine use. Review of Nurse's Note dated 11/07/16, 11/08/16 revealed patient #2 had new PEG tube and the site to abdomen had moderate serosanguinous drainage and patient also complained of pain at site. Review of the Discharge Instructions form dated 11/09/16 and timed 5:45 p.m. revealed that it was not completed or signed. There was no documented evidence reflecting the patient's vital signs or assessment at the time of discharge. Review of Nurses Note dated 11/09/16 at 6:20 p.m. revealed the local sheriffs office was notified for transport. At 7:55 p.m. patient out of facility in sheriff's office vehicle in-route to hospital (b) for evaluation. There was no other documentation or assessment of the patient's condition at the time of discharge.Interview on 12/20/16 at 1:00 p.m. with S1Administrator verified that patient #2 was transported by the the sheriff's office to the recieving hospital. S1Administrator stated that it was the facilities policy to use the sheriff's office to transport patients with behaviors unless there was a medical reason requiring an ambulance. S1Administrator returned at 1:20 p.m. and stated that she could not find any hospital policy stating to use the sheriff's office for transport of behavioral patients, but it was what was always used for the hospital. S1Administrator confirmed that there should have been documentation of an assessment at the time of discharge of the patient.

Based on record review and interview, the hospital failed to ensure the hospital's criteria and screening process for a discharge planning evaluation was correctly applied by failing to have completed a discharge planning evaluation for 1 (#2) of 4 patients who's medical record was reviewed for discharge planning from a total sample of 5 patients. Findings:Review of the hospital policy titled "Discharge Planning", presented as a current policy by S1Administrator, Number 3.04, effective date 6/2015 revealed in part: Discharge Planning begins upon admission and is completed when every aspect of aftercare needed by the patient has been arranged. The Case Management Department representative will initiate the discharge planning process by completing the discharge planning assessment form within 48 hours of admission. The Case Management Department representative will document all aspects of their involvement relevant to discharge planning in the patient's medical chart. Complete the Discharge Planning Assessment form, making sure there is a response for all areas on the form.Review of Pre-Admission Screen dated 11/02/16 revealed patient #2 was a 54 year old male admitted to hospital (a) on 10/24/16 for possible stroke and was followed up with neuro with a CT scan on 10/24/16 and repeated on 10/26/16 with no indications of cranial bleeding. The patient was positive for cocaine on his drug screen. Patient #2 had a PEG tube placed during admission due to dysphagia. Progress note dated 10/24/16 revealed after neurology consult to keep an eye on patients mental status because if it is due to drugs he may go into violent behaviors.Review of patient #2 's medical record revealed he had been admitted to the Tri Parish Rehabilitation hospital on 11/07/16 with diagnoses of CVA with Right Hemiparesis, A-Fib, Dysphagia, Dysarthria, CHF, CAD, COPD, Obesity, History of Cocaine use. He currently is min-mod assist with ADL's and ambulation and max assist with verbalization. Physician is requesting intense therapy to maximize patient's functional mobility allowing him to return home at highest functional independence. He is stable to participate in intense therapy at this time. Further review revealed Facsimile Cover Letters dated 11/08/16 at 1:45 p.m. to hospital (c) ; 11/08/16 at 4:40 p.m. to hospital (d); 11/08/16 at 5:00 p.m. to hospital (e); and 11/09/16 at 5:23 p.m. to hospital (b) Unit 54. There was no documentation other than the cover letter. Patient #2 was discharged to hospital (b) by a PEC on 11/09/16 for violent behaviors, danger to self, and danger to others. Review of the Discharge Instructions form dated 11/09/16 and timed 5:45 p.m. revealed that it was not completed or signed. There was no documented evidence reflecting the patients discharge in the medical record.Interview on 12/19/16 at 2:00 p.m. with S3LPN confirmed that she was the case manager for the discharge of patient #2. Surveyor asked S3LPN about the 4 Facsimile letters for transfer in the patient's record and she stated that the referral dated 11/08/16 at 1:45 p.m. to hospital (c) was the first facility she had tried for placement, but they refused the patient because of his medical status with the PEG tube. The second referral to hospital (d) on 11/08/16 at 2:40 p.m. also refused because of the PEG tube status. The third attempt for placement on 11/08/16 at 5:00 p.m. at hospital (e) a psych facility was also refused. The fourth attempt on 11/09/16 at 5:23 p.m. to hospital (b) Unit 54 had accepted the patient. S3LPN did not remember with whom she spoke with at hospital (b). S3LPN further stated that she did make contact with the patient's family and spoke with them about discharging the patient and the family requested that he was sent somewhere close to Lake Charles where the patient was from. Surveyor requested information regarding the discharge documentation and was told from S3LPN that she had some notes in her office. Interview on 12/19/16 at 3:00 p.m. with S3LPN confirmed that she did not have any documentation on the discharge of patient #2 or documentation with whom she spoke with at hospital (b) that told her they would accept the patient. S3LPN further stated that she did not know why the discharge form had not been completed.Interview on 12/20/16 at 11:55 a.m. with S2DON confirmed there was no documentation to reflect the patient 's condition or disposition at the time of discharge and there was no documentation of a discharge plan documented in the patient's record.

Based on record review and interview, the hospital failed to ensure staff members responsible for discharge planning activities followed the hospital's policy for discharge planning evaluation for 1 (#2) of 4 patients who's medical record was reviewed for discharge planning from a total sample of 5 patients. Findings:Review of the hospital policy titled "Discharge Planning", presented as a current policy by S1Administrator, Number 3.04, effective date 6/2015 revealed in part: Discharge Planning begins upon admission and is completed when every aspect of aftercare needed by the patient has been arranged. The Case Management Department representative will initiate the discharge planning process by completing the discharge planning assessment form within 48 hours of admission. The Case Management Department representative will document all aspects of their involvement relevant to discharge planning in the patient's medical chart. Complete the Discharge Planning Assessment form, making sure there is a response for all areas on the form.Review of patient #2's medical record revealed he had been admitted to the Tri Parish Rehabilitation hospital on 11/07/16 with diagnoses of CVA with Right Hemiparesis, A-Fib, Dysphagia, Dysarthria, CHF, CAD, COPD, Obesity, History of Cocaine use. He currently is min-mod assist with ADL's and ambulation and max assist with verbalization. Physician is requesting intense therapy to maximize patient's functional mobility allowing him to return home at highest functional independence. He is stable to participate in intense therapy at this time. Further review revealed Facsimile Cover Letters dated 11/08/16 at 1:45 p.m. to hospital (c); 11/08/16 at 4:40 p.m. to hospital (d); 11/08/16 at 5:00 p.m. to hospital (e); and 11/09/16 at 5:23 p.m. to hospital (b) Unit 54. There was no documentation other than the cover letter. Patient #2 was discharged to hospital (b) by a PEC on 11/09/16 for violent behaviors, danger to self, and danger to others. Review of the Discharge Instructions form dated 11/09/16 and timed 5:45 p.m. revealed that it was not completed or signed. There was no documented evidence reflecting of a discharge screening assessment or any Case Management progress note in the medical record.Interview on 12/19/16 at 3:00 p.m. with S3LPN confirmed that she did not have any documentation regarding the discharge of patient #2. Interview on 12/20/16 at 11:55 a.m. with S2DON confirmed there was no documentation to reflect a discharge plan or evaluation was implemented for patient #2.

Based on record review and interview, the hospital failed to ensure staff members responsible for Discharge Planning were appropriately trained and/or qualified to ensure for the effective implementation of the discharge planning relative to patient care. Findings:

Review of the hospital job description titled "Nurse Case Manager," presented by S1Administrator, revealed in part: Requirements; current un-restricted nurse license in the state of Louisiana, BSN preferred, CPR certification, CCMC certification preferred, At least 2 years of utilization review/case management experience in inpatient hospital setting, inpatient rehabilitation experience preferred.Review of the personnel record for S3LPN revealed original date of hire was 09/19/14 for staff nurse with PRN status. Further review revealed on 11/29/15 S3LPN was hired full time for Case Manager/Discharge Planner. Job Description form titled "Position Description/Performance Evaluation," dated 11/29/15 for new job title Nurse Case Manager was blank and the competency areas were not documented. Further review revealed no training or experience documented in the personnel record to reflect S3LPN had any qualified training or experience in Case Management or Discharge Planning prior to hire date of 11/29/15. Interview on 12/21/16 at 11:00 a.m. with S1Administrator verified that she had only been here as the Administrator since 10/31/16 and S2DON verified that she had started in March 2016. S1Administrator after reviewing S3LPN personnel record confirmed that there was no documentation of previous experience for case management or discharge planning. S2DON stated that S3LPN was working with another seasoned discharge planner but there was no documented evidence in the personnel record. S1Administrator confirmed there was no documented evidence that S3LPN met the requirements for Nurse Case Manager as indicated in the hospitals job description.