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Based on interview and record review the facility failed to plan and coordinate the transfer/discharge for 1 of 30 sampled patients (41). Patient 41's discharge plan had not been completed or communicated in a manner which assured that a coordinated exchange of information was provided to meet the needs of the patient. Patient 41 was allowed to be transported to a skilled nursing facility (SNF)prior to the completion and final approval of the discharge plan and without a report from the hospital nursing staff to the SNF. The receiving SNF could not accept the patient, due to the incomplete transfer arrangements, and the patient had to be be transported back to the hospital for completion of the discharge plans.

Findings:

Patient 41 was admitted to the facility on 10/19/15 with diagnoses which included chronic obstructive pulmonary disease (COPD-a lung disorder which affect the ability to breath) per the Admission History and Physical Examination.

During an interview on 12/1/15 at 1:15 P.M., the Case Manager (CM) stated stated that Patient 41's discharge plans had been initiated on 11/30/15 with discussions with the patient's primary physician. The CM stated the details of the discharge plan had not yet been completed, when a contracted transport service arrived, on 12/1/15, and transported the patient to the SNF. CM stated that she had not learned that the patient had left the hospital until the patient was returned by the transport service.

During an interview on 12/1/15 at 2:45 P.M., Registered Nurse (RN) 24 stated he had been assigned to Patient 41 at the time of the patient's transport to the SNF. RN 24 stated he recalled discussions of the patient's discharge from the day prior and seen a physician order for the discharge on the patient's chart. RN 24 stated that when a contracted transport service arrived, he "assumed" that the patient was prepared for discharge. RN 24 stated that he had not given a verbal report to the SNF prior to the patient's transport out of the hospital. RN 24 stated that he attempted a phone call to the SNF nursing staff, waited "5 to 10 minute then hung up". RN 24 stated that he did not attempt to call back and that the contracted transport service returned the patient to the hospital "about an hour later".

A review of the hospital policy and procedure, entitled Discharge Planning included "Case Managers will provide individual discharge planning to all patients through assessment of discharge needs at admission, development of a discharge plan, implementation of the plan, evaluation of the appropriateness of the plan with on-going monitoring, and the coordination of final preparations for discharge....Transfers to referral facilities/agencies must include necessary medical information including, but not limited to: Brief reason for hospitalizations and brief description of hospital course of treatment. Patient condition at discharge..."

During an interview on 12/1/15 at 3:00 P.M., the Director of Case Management (DCM) stated that Patient 41's discharge plan status had been identified as "pending" at the time of the patient's transport and the nursing staff should not have allowed the transport to occur without communication with the CM. In addition, DCM stated hospital nursing staff were expected to conduct a verbal report to the receiving facility staff prior to the actual patient discharge and transport.