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Based on interview and record review, the facility failed to ensure patient rights were implemented, for one of 30 sampled patients (Patient 3), when the patient or her family was not notified of the patient's change of condition.

This failure resulted in Patient 3 and her family to not be informed of the change in Patient 3's condition and had potential for Patient 3 and/or her family to not be able to participate in decision making regarding the patient's plan of care.

Findings:

On November 17, 2025, at 2:30 p.m., a review of Patient 3's record was conducted with the Stroke Program Coordinator (SPC). A facility document titled, "Admission H&P [History and Physical]...," dated March 15, 2025, was reviewed. The document indicated Patient 3 had a medical history of cerebral vascular accident (stroke, loss of blood flow to a part of the brain), atrial fibrillation (a rapid, irregular heartbeat caused by a problem with the heart's electrical signals), peripheral artery disease (condition where arteries which supply blood to the legs and feet become narrowed or blocked), and hypertension (high blood pressure, normal is 120/80). The document indicated Patient 3 was admitted to the facility on March 15, 2025, for a fall, and pelvic and hip fracture (a break in the bones).

On November 17, 2025, at 2:45 p.m., a facility document titled, "Case Management Reassessment," dated March 17, 2025, at 5:23 p.m., authored by Social Worker (SW) 1 was reviewed. The document indicated, "...Emergency contact is her [family member, FM] [Name of FM]...[FM] acts as her surrogate agent..."

On November 17, 2025, at 3 p.m., a facility document titled, "Progress Note- Nursing...Result Detail...," dated March 23, 2025, at 11:43 a.m., authored by registered nurse (RN) 1 was reviewed. The document indicated, "...Physician communication....Patient [Patient 3] condition...MD [physician] notified pt [Patient 3] having [sic] difficulty coming in with her words, and has R [right] upper and lower extremity [arms and legs] jitterness [sic] and weakness. Per MD he will order CT [computerized tomography, an imaging procedure] of the head..."

On November 17, 2025, at 3:02 p.m., a facility document titled, "Order Sheet," dated March 23, 2025, at 11:43 a.m., authored by MD 1 was reviewed. The document indicated, "...CT Head or Brain W/O [without] Contrast [a substance used to improve the visibility of internal body structures]...Reason For Exam...upper extremity [arms] tremor [shaking]..."

On November 17, 2025, at 3:05 p.m., a facility document titled, "Final Report," dated March 23, 2025, at 1:32 p.m., authored by Radiology Technician (RT) 1 was reviewed. The document indicated, "...Small amount of intraventricular hemorrhage [IVH, bleeding which occurs inside or around the brain's ventricles (which are C-shaped fluid-filled spaces in the brain)] within the right lateral ventricle [one of two ventricles in the brain], new since previous exam..."

On November 17, 2025, at 3:10 p.m., a facility document titled, "Progress Note...," dated March 23, 2025, at 1:42 p.m., was reviewed. The document indicated, "...consulted neurosurgeon on-call [name of MD] who recommended neuro ICU [intensive care unit, a unit for critically ill patients] admission with frequent neuro checks [a series of tests to assess the brain's condition], seizure [convulsions] prophylaxis [the use of medication to prevent seizures in individuals at high risk], keep blood pressure less than 140 at all times and repeat CT head in AM [morning]. Consulted intensivist [a physician who specialized in treating critically ill patients]...Discussed with nursing..."

There was no documented evidence Patient 3 or her family was notified about the change in Patient 3's condition.

On November 19, 2025, at 10 a.m., an interview and concurrent review of Patient 3's record were conducted with the Chief Medical Officer (CMO). The CMO stated there was no documentation Patient 3's change of condition was discussed with Patient 3 or her family.

On November 19, 2025, at 11 a.m., an interview was conducted with the Director of Telemetry (unit where patients' heart rates and rhythms are continuously monitored remotely) 3 (D3E)). The D3E stated the patient and/or the patient's family should be notified of a change in the patient's condition, depending on the patient's ability to understand. The D3E stated the primary responsibility of notifying the patient or the patient's family is with the physician.

On November 19, 2025, at 12:13 p.m., an interview was conducted with the Regulatory Manager (RM). The RM stated she was unable to find documentation Patient 3 or her family was notified of Patient 3's change of condition. The RM stated the facility has no policy and procedure (P&P) for notification of the patient or the patient's family about a change in the patient's condition.

A review of the P&P titled, "Patient Rights And Responsibilities," revised September 18, 2025, was conducted. The P&P indicated, "...It is the responsibility of [name of facility] and its staff to protect and promote each patient's rights...Receive information about your health status, diagnosis [the nature of an illness], prognosis [a forecast of the likely course of a disease], course of treatment, prospects of recovery and outcomes of care (including unanticipated outcomes)..."

Based on interview and record review, the facility failed to ensure its policy and procedure (P&P) were implemented, for three of 30 sampled patients (Patients 3, 18, and 26), when:

1. For Patient 3, the facility P&P for patient rights was not implemented when a change of condition was not discussed with the patient or family. In addition, coordination of care was not facilitated when Patient 3 and her family requested transportation to transfer Patient 3 to another state where the patient resides;

2. For Patient 18, the required services for a homeless patient were not offered before discharge in accordance with the facility P&P titled,"...Homeless Discharge Planning," and "...Pre-Discharge Services for Homeless Patient;" and

3. For Patient 26, the pain reassessment did not include a pain scale (a tool used to measure and describe the severity of pain using a numerical rating from 0 [no pain] to 10 [worst possible pain]), to assess the effectiveness of or Patient 26's response to the pain medication administered, in accordance with the facility's P&P titled, "Adult Pain Management."

These failures had the potential to cause delays in the provision of care for Patients 3, 18, and 26.

Findings:

1a. On November 17, 2025, at 2:30 p.m., a review of Patient 3's record was conducted with the Stroke Program Coordinator (SPC). A facility document titled, "Admission H&P [History and Physical]...," dated March 15, 2025, was reviewed. The document indicated Patient 3 had a medical history of cerebral vascular accident (stroke, loss of blood flow to a part of the brain), atrial fibrillation (a rapid, irregular heartbeat caused by a problem with the heart's electrical signals), peripheral artery disease (condition where arteries which supply blood to the legs and feet become narrowed or blocked), and hypertension (high blood pressure, normal is 120/80). The document indicated Patient 3 was admitted to the facility on March 15, 2025, for a fall, and pelvic and hip fracture (a break in the bones).

On November 17, 2025, at 3 p.m., a facility document titled, "Progress Note- Nursing...Result Detail...," dated March 23, 2025, at 11:43 a.m., authored by registered nurse (RN) 1 was reviewed. The document indicated, "...Physician communication....Patient [Patient 3] condition...MD [physician] notified pt [Patient 3] having [sic] difficulty coming in with her words, and has R [right] upper and lower extremity [arms and legs] jitterness [sic] and weakness. Per MD he will order CT [computerized tomography, an imaging procedure] of the head..."

On November 17, 2025, at 3:02 p.m., a facility document titled, "Order Sheet," dated March 23, 2025, at 11:43 a.m., authored by MD 1 was reviewed. The document indicated, "...CT Head or Brain W/O [without] Contrast [a substance used to improve the visibility of internal body structures]...Reason For Exam...upper extremity [arms] tremor [shaking]..."

On November 17, 2025, at 3:05 p.m., a facility document titled, "Final Report," dated March 23, 2025, at 1:32 p.m., authored by Radiology Technician (RT) 1 was reviewed. The document indicated, "...Small amount of intraventricular hemorrhage [IVH, bleeding which occurs inside or around the brain's ventricles (which are C-shaped fluid-filled spaces in the brain)] within the right lateral ventricle [one of two ventricles in the brain], new since previous exam..."

On November 17, 2025, at 3:10 p.m., a facility document titled, "Progress Note...," dated March 23, 2025, at 1:42 p.m., was reviewed. The document indicated, "...consulted neurosurgeon on-call [name of MD] who recommended neuro ICU [intensive care unit, a unit for critically ill patients] admission with frequent neuro checks [a series of tests to assess the brain's condition], seizure [convulsions] prophylaxis [the use of medication to prevent seizures in individuals at high risk], keep blood pressure less than 140 at all times and repeat CT head in AM [morning]. Consulted intensivist [a physician who specialized in treating critically ill patients]...Discussed with nursing..."

There was no documented evidence Patient 3 or her family was notified about the change in Patient 3's condition.

On November 19, 2025, at 10 a.m., an interview and concurrent review of Patient 3's record were conducted with the Chief Medical Officer (CMO). The CMO stated there was no documentation Patient 3's change of condition was discussed with Patient 3 or her family.

On November 19, 2025, at 11 a.m., an interview was conducted with the Director of Telemetry (unit where patients' heart rates and rhythms are continuously monitored remotely) 3 (D3E)). The D3E stated the patient and/or the patient's family should be notified of a change in the patient's condition, depending on the patient's ability to understand.

On November 19, 2025, at 12:13 p.m., an interview was conducted with the Regulatory Manager (RM). The RM stated she was unable to find documentation Patient 3 or her family was notified of Patient 3's change of condition. The RM stated the facility has no policy and procedure (P&P) for notification of the patient or the patient's family about a change in the patient's condition.

A review of the P&P titled, "Patient Rights And Responsibilities," revised September 18, 2025, was conducted. The P&P indicated, "...It is the responsibility of [name of facility] and its staff to protect and promote each patient's rights...Receive information about your health status, diagnosis [the nature of an illness], prognosis [a forecast of the likely course of a disease], course of treatment, prospects of recovery and outcomes of care (including unanticipated outcomes)..."

b. On November 17, 2025, at 2:50 p.m., a facility document titled, "Progress Note," dated March 16, 2025, at 4:42 p.m., authored by MD 2, was reviewed. The document indicated, "...[family member, FM] is at bedside and they live in [name of a state]...She would like transport [Patient 3] home...have discussed surgical verus [sic, versus, against] nonsurgical options with hip replacement [a surgical procedure where a damaged hip joint is replaced with an artificial implant] in the future. She [Patient 3] is very frail and has severe PAD [peripheral artery disease]. I discussed my concern about performing an ORIF [open reduction internal fixation, a surgical procedure to treat fractures] of the acetabulum [the socket of the hip bone]...She [FM] would like to discuss with social work possible transport home..."

On November 17, 2025, at 3:50 p.m., a facility document titled, "Progress Note," dated March 17, 2025, at 5:08 p.m., authored by MD 3 was reviewed. The document indicated, "...[FM] is at bedside who states goal is to get patient back to [name of a state] as soon as possible...Patient and family requesting to speak with social worker and case management to see if there is any available resources that could help with getting patient back to [name of a state]...Consult case management and social worker..."

On November 17, 2025, at 3:55 p.m., a review of the facility document titled, "Case Management Reassessment," dated March 17, 2025, at 5:23 p.m., authored by Social Worker (SW) 1 was reviewed. The document indicated, "...Consult ordered 3/16/25 [March 16, 2025], DCP [direct care provider] patient's [FM] [name of FMr] would like options on getting patient back home...Pt [Patient 3] insured through [name of insurance]...[FM] states neither her nor [Patient 3] are able to afford to hire medical transportation...pt expressed feeling stressed and guilty about the situation...SW provided hope her [FM] would figure out a solution...[FM]...stated pt's PCP [primary care provider] informed her to "get pt to [name of a state] asap [as soon as possible]...SW spoke with [FM] and outlined option, including what insurance will and will not cover. SW explained Medicare only covers a limited number of miles. SW also explained that some...HMOs [health maintenance organization, a type of managed health insurance plan] provide transportation via their [name of insurance] plans and suggested she contact [name of state] [name of insurance] to inquire if they have resources to assist in getting pt back home...[FM] expressed frustration and disappointment...Most options for medical transportation home would require out-of-pocket expense, which was explained to both pt and [FM]. SW provided next day SW with above information and requested she continue to explore options with [FM] and team..."

There was no documented evidence insurance discussion or estimates of payment and/or out-of-pocket costs for transportation to another state was discussed with Patient 3 or Patient 3's FM.

On November 18, 2025, at 12:15 p.m., an interview was conducted with the Manager of Social Work (MSW). The MSW stated Care coordination is part of the social worker's role. The MSW stated she would want to call to arrange for transfer of the patient because "that's where their support system and established care are, there is familiarity, it is the patient's preference..."

On November 19, 2025, at 12:30 p.m., an interview was conducted with the DCM. The DCM stated she was not able to find documentation of insurance contact or proof of cost of coverage for transportation to another state were discussed with Patient 3 or her FM. The DCM stated what usually happens is for the facility to figure out what agency is needed by the patient and what the contracted services are. The DCM stated the facility would then talk to the patient and the patient's family and try to get their choice, then they would call the insurance and state family is requesting to go home and the insurance would let them know if the insurance is requesting the patient to go back in-network (within the covered area of the insurance). The DCM stated, if the insurance is not requesting in-network, then the responsibility goes to the patient and the facility would let the patient know what the patient is responsible for and would get a list of quotes to provide to the patient.

A review of the facility P&P titled, "Hospital Case Management Transition Planning," dated June 22, 2023, indicated, "...Transition planning includes coordination of hospital, community providers, and support systems to enable the patient to return home safely or through the referral process, place the patient at the appropriate level of care. The discharge planning process addresses all transitions between levels of care with an emphasis on continuity of care...Case Management will determine and utilize patient/caregiver goals and preferences...Once the Case Management...or Social Worker complete the transition evaluation and plan...make the necessary arrangements required to execute the transition plan including arranging...transportation...Case Management staff will document the...plan...patient choice or preferences...in the patient's medical record..."

2. On November 17, 2025, at 2:56 p.m., a review of Patient 18's record was conducted with the Sepsis Program Coordinator (SPC) 2. An ambulance document titled, "Patient Care Report," dated August 22, 2025, was reviewed. The document indicated, "...14:12 [2:12 p.m.]...identification...[Patient 18's Name]...home address...Homeless..."

A facility document titled, "ED [Emergency Department] Note Physician," dated August 22, 2025, was reviewed. The document indicated, "...14:52 [2:52 p.m.]...with history of schizophrenia [a mental disorder characterized by a distorted perception of reality], and methamphetamine [a powerful and highly addictive stimulant (a substance which produce effects such as heightened alertness, increased energy, and elevated mood)] abuse brought in by ambulance for heat exhaustion. Patient states he was recently kicked out of a home he should be staying in and is now staying on the streets. He would like to speak with the social worker about getting off the streets..."

A facility document titled, "Homeless Patient Identification Form," dated August 22, 2025, was reviewed. The document indicated, "...Permanent Housing...Questions 1: Do you have a fixed and regular night-time residence...no... if no: The patient is considered "homeless"...under the homeless patient discharge planning law..."

A facility document titled, "ED disposition," dated August 22, 2025, was reviewed. The document indicated, "...1546 [3:46 p.m.] ED discharged...home..."

A facility document titled, "ED Note Physician," dated August 22, 2025, was reviewed. The document indicated Patient 18 was seen again at the ED on August 22, 2025, at 9:47 p.m. The document indicated, "...08/22/25 [August 22, 2025]22:31 [10:31 p.m.]...Chief Complaint...Rash/Itching, felt food poisoning...History of present illness... Patient [Patient 18] was seen her [sic, here] earlier today and discharged...Requesting to see the social worker, however, social worker has gone home for the day..."

A facility document titled, "Order Sheet," dated August 22, 2025, was reviewed. The document indicated, "...Social Service Consult...STAT...08/22/25 [August 22, 2025] 21:48 [9:48 p.m.] ...Homeless..."

A review of the facility document titled, "ED Discharge Form," dated, August 22, 2025, indicated, "...22:54 [10:54 p.m.]PDT...ED Discharged...Home..."

There was no documented evidence a consult with a social worker was ordered and the required services for a homeless patient, which included infection disease screening, vaccinations, recommendations for follow up care, clothing, discharge medications, transportation and affordable health coverage, were offered to Patient 18 before Patient 18 was discharged on August 22, 2025, at 3:46 p.m.

There was no documented evidence a social worker assessed Patient 18 prior to the patient's discharge on August 22, 2025, at 10:54 p.m.

During a concurrent interview with the SC, the SC stated she was unable to find documentation a social worker assessed Patient 18 before the patient was discharged. The SC stated he was unable to find documentation the required services for a homeless patient were offered to Patient 18 before Patient 18 was discharged.

On November 18, 2025, at 12:19 p.m., a concurrent interview and review of Patient 18's record were conducted with the Social Work Manager (SWM). A facility document titled, "Clinical Resource Management Department Assignment," dated August 22, 2025, was reviewed. The document indicated, "...Unit...ED...Social Worker...[name of SW] ..." The SWM stated the Social Worker (SW) assigned to the ED that day left at 3:30 p.m. but there was SW coverage until 4:30 pm. The SWM further stated after 4:30 p.m., there was no SW assigned to consult specifically for the homeless patients in the ED and the homeless patient will be seen the following day at 7 a.m., if the patient is still there.

A concurrent interview and review of Patient 18's record were conducted on November 19, 2025, at 1:10 p.m., with the ED Director (EDD) and ED Manager (EDM). The EDD stated there was no documentation the required services for homeless patients, such as shelter, infectious disease screening, vaccinations, clothing, transportation and affordable health coverage, were offered to Patient 18 before Patient 18 was discharged.

A concurrent interview and review of the facility's P&Ps titled, " ...Homeless Discharge Planning," and " ...Pre-Discharge Services for Homeless Patient," dated February 16, 2023, were conducted on November 18, 2025, at 1:15 p.m., with the EDD and EDM. The EDD stated there was no documentation the facility's staff offered the required services to Patient 18 before Patient 18 was discharged in accordance with the facility's P&P.

A review of the P&P titled," " ...Homeless Discharge Planning," dated February 16, 2023, was conducted. The P&P indicated,"...Offer services to Homeless Patients Prior to Discharge...Hospital will offer various services to Homeless Patients prior to discharge as outlined ...PRE-DISCHARGE SERVICES FOR HOMELESS PATIENT ..."

A review of the P&P titled, " ...Pre-Discharge Services for Homeless Patient, " dated February 16, 2025, was conducted. The P&P indicated, "...Infection disease Screening...Hospital staff will offer the homeless patient screening for infectious disease common to the region...Vaccinations...Hospital staff will offer the homeless patient appropriate to their presenting medical condition...Clothing...If the homeless patient does not arrive with weather- appropriate clothing, the Hospital staff will offer weather-appropriate clothing and encourage the patient to change into weather appropriate clothing and encourage to change into weather-appropriate clothing before leaving the hospital...Transportation... Hospital staff will offer the homeless patient transportation after discharge to his or her post discharge destination...Assistance with Affordable Health Coverage...The hospital staff will screen the homeless patient for and offer assistance with enrolling in any affordable health insurance coverage for which he or she is eligible..."

3. On November 18, 2025, at 11:30 a.m., a review of Patient 26's record was conducted with the RM. A facility document titled, "Admission History & Physical," dated October 17, 2025, was reviewed. The document indicated Patient 26 was admitted to the facility on October 13, 2025, with a chief complaint of altered level of consciousness (a state when a person is not alert, awake, and/or fully aware of their surroundings) and right sided weakness. The document indicated on October 13, 2025, patient had a surgery to remove a clot on the left side of her brain.

A facility document titled, "Order Sheet," dated October 29, 2025, was reviewed. The document indicated, "...acetaminophen-Hydrocodone (a strong pain medication] 325 mg [milligrams, unit of measurement]- 5 [five] mg tab [tablet] 1 [one] tab...Tube [gastrostomy tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems] Q [every] 4 [four] hr [hours]...Pain Moderate, 6 [six, pain score for a pain scale of one to 10, 10 meaning most severe pain], Routine [administered regularly]..."

A facility document titled, "Medication Administration," dated November 4, 2025, was reviewed. The document indicated acetaminophen-Hydrocodone 325 mg-5mg one tablet was administered on November 4, 2025, at 1:53 p.m., by Registered Nurse (RN) 11.

A facility document titled, "PRN [to be administered as needed] Response Form Task," dated November 4, 2025, at 2:53 p.m., was reviewed. The document indicated, "...Medication Effectiveness & Pain Response Form: Medication Administration Painison[sic]: Medication Effective: No Medication Response: Continue to observe for symptoms..."

There was no documented evidence a pain score was assigned for Patient's 26 response to the administered pain medication.

On November 18, 2025, at 2 p.m., a review of Patient 26's record and concurrent interview was conducted with the Clinical Manager (CM). The CM stated the pain reassessment must be completed by the RN within an hour of administration of the pain medication and must include the reassessment of the pain score.

A review of the facility's P&P titled, "Adult Pain Management," dated December 19, 2024, was conducted. The P&P indicated, "...Documentation of pain assessment consists of the following...Date and time of assessment...Patient's comfort goal [acceptable pain intensity]...Location of pain...Appropriate pain scale...Reassessment shall be documented within 60 minutes post intervention, and based on the patient's condition which includes evaluation of sedation [a state of calmness, relaxation or sleepiness induced by medication] as well as appropriate vital signs..."

Based on interview and record review, the facility failed to ensure the facility's policy and procedure (P&P) was implemented, for one patient of 30 sampled patients (Patient 3), when coordination of care was not facilitated after Patient 3 and her family requested to return to home residence out of state.

This failure had the potential to cause delays in the provision of care to Patient 3.

Findings:

On November 17, 2025, at 2:30 p.m., a review of Patient 3's record was conducted with the Stroke Program Coordinator (SPC). A facility document titled, "Admission H&P [History and Physical]...," dated March 15, 2025, was reviewed. The document indicated Patient 3 had a medical history of cerebral vascular accident (stroke, loss of blood flow to a part of the brain), atrial fibrillation (a rapid, irregular heartbeat caused by a problem with the heart's electrical signals), peripheral artery disease (condition where arteries which supply blood to the legs and feet become narrowed or blocked), and hypertension (high blood pressure, normal is 120/80). The document indicated Patient 3 was admitted to the facility on March 15, 2025, for a fall, and pelvic and hip fracture (a break in the bones).

On November 17, 2025, at 2:45 p.m., a facility document titled, "Case Management Reassessment," dated March 17, 2025, at 5:23 p.m., authored by Social Worker (SW) 1 was reviewed. The document indicated, "...Emergency contact is her [family member, FM] [Name of FM]...[FM] acts as her surrogate agent..."

On November 17, 2025, at 2:50 p.m., a facility document titled, "Progress Note," dated March 16, 2025, at 4:42 p.m., authored by MD 2, was reviewed. The document indicated, "...[family member, FM] is at bedside and they live in [name of a state]...She would like transport [Patient 3] home...have discussed surgical verus [sic, versus, against] nonsurgical options with hip replacement [a surgical procedure where a damaged hip joint is replaced with an artificial implant] in the future. She [Patient 3] is very frail and has severe PAD [peripheral artery disease]. I discussed my concern about performing an ORIF [open reduction internal fixation, a surgical procedure to treat fractures] of the acetabulum [the socket of the hip bone]...She [FM] would like to discuss with social work possible transport home..."

On November 17, 2025, at 3:50 p.m., a facility document titled, "Progress Note," dated March 17, 2025, at 5:08 p.m., authored by MD 3 was reviewed. The document indicated, "...[FM] is at bedside who states goal is to get patient back to [name of a state] as soon as possible...Patient and family requesting to speak with social worker and case management to see if there is any available resources that could help with getting patient back to [name of a state]...Consult case management and social worker..."

On November 17, 2025, at 3:55 p.m., a review of the facility document titled, "Case Management Reassessment," dated March 17, 2025, at 5:23 p.m., authored by Social Worker (SW) 1 was reviewed. The document indicated, "...Consult ordered 3/16/25 [March 16, 2025], DCP [direct care provider] patient's [FM] [name of FMr] would like options on getting patient back home...Pt [Patient 3] insured through [name of insurance]...[FM] states neither her nor [Patient 3] are able to afford to hire medical transportation...pt expressed feeling stressed and guilty about the situation...SW provided hope her [FM] would figure out a solution...[FM]...stated pt's PCP [primary care provider] informed her to "get pt to [name of a state] asap [as soon as possible]...SW spoke with [FM] and outlined option, including what insurance will and will not cover. SW explained Medicare only covers a limited number of miles. SW also explained that some...HMOs [health maintenance organization, a type of managed health insurance plan] provide transportation via their [name of insurance] plans and suggested she contact [name of state] [name of insurance] to inquire if they have resources to assist in getting pt back home...[FM] expressed frustration and disappointment...Most options for medical transportation home would require out-of-pocket expense, which was explained to both pt and [FM]. SW provided next day SW with above information and requested she continue to explore options with [FM] and team..."

There was no documented evidence insurance discussion or estimates of payment and/or out-of-pocket costs for transportation to another state was discussed with Patient 3 or Patient 3's FM.

On November 18, 2025, at 12:15 p.m., an interview was conducted with the Manager of Social Work (MSW). The MSW stated Care coordination is part of the social worker's role. The MSW stated she would want to call to arrange for transfer of the patient because "that's where their support system and established care are, there is familiarity, it is the patient's preference..."

On November 19, 2025, at 12:30 p.m., an interview was conducted with the DCM. The DCM stated she was not able to find documentation of insurance contact or proof of cost of coverage for transportation to another state were discussed with Patient 3 or her FM. The DCM stated what usually happens is for the facility to figure out what agency is needed by the patient and what the contracted services are. The DCM stated the facility would then talk to the patient and the patient's family and try to get their choice, then they would call the insurance and state family is requesting to go home and the insurance would let them know if the insurance is requesting the patient to go back in-network (within the covered area of the insurance). The DCM stated, if the insurance is not requesting in-network, then the responsibility goes to the patient and the facility would let the patient know what the patient is responsible for and would get a list of quotes to provide to the patient.

A review of the facility P&P titled, "Hospital Case Management Transition Planning," dated June 22, 2023, indicated, "...Transition planning includes coordination of hospital, community providers, and support systems to enable the patient to return home safely or through the referral process, place the patient at the appropriate level of care. The discharge planning process addresses all transitions between levels of care with an emphasis on continuity of care...Case Management will determine and utilize patient/caregiver goals and preferences...Once the Case Management...or Social Worker complete the transition evaluation and plan...make the necessary arrangements required to execute the transition plan including arranging...transportation...Case Management staff will document the...plan...patient choice or preferences...in the patient's medical record..."