HospitalInspections.org

Based on review of medical records (MR), review of facility documents, and interview with staff (EMP), it was determined the facility did not properly implement the discharge plan for failing to reconcile oxygen needs and failing to include home Phyical Therapy needs on the patients discharge instructions for two of five medical records reviewed (MR2 and MR5).

Findings include:

A review of the facility's Medical Staff Bylaws dated May 2014 revealed " ... 2.10 Discharge from the Hospital. The decision to discharge a patient is a nondelegable duty of the Attending physician/podiatrist/dentist/oral surgeon. Attending physician/podiatrist/dentist/oral surgeon must see the patient prior to discharge or, when medically appropriate, see the patient within 24 hours of discharge and leave specific discharge criteria for the provider who is to see the patient prior to discharge. The Attending physician/podiatrist/dentist/oral surgeon is responsible for assuring that the patient has appropriate instructions at discharge. The decision to discharge, with any accompanying discharge instructions, must be documented in the medical record by the Attending physician/podiatrist/dentist/oral surgeon or his/her designee. ... "

A review of MR2 revealed a case management note dated September 2, 2015, which revealed " ... pt has been cleared by P.T. [Physical Therapy] to be dc'd home with home P.T. Referral placed ... ". A further review of MR2's discharge instructions revealed no documented evidence of Home Physical Therapy as follow up care for MR2.

An interview with EMP1 on September 9, 2015, at 11:45 AM confirmed MR2 discharge instructions revealed no documented evidence of Home Physical Therapy as follow up care for MR2.

A review of MR5 revealed MR5 presented to the hospital with shortness of breathe when walking and MR5 had a physician order for Oxygen via a nasal cannula at 2 liter per minute. A further review of MR5's discharge instructions revealed no documented evidence to continue or discontinue the oxygen therapy at home.

An interview with EMP1 on September 9, 2015, at 11:55 AM confirmed MR5's discharge instructions revealed no documented evidence to continue or discontinue the oxygen therapy at home.