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Based on interviews and record review the facility failed to reassess discharge plans for changes which potentially warranted adjustment to the plan. Specifically, staff failed to reassess a patient's oxygenation and urination status in 1 of 10 patients reviewed (Patient #3). Furthermore, the facility failed to provide a discharge summary in 3 of 10 charts reviewed (Patients #3, #7 and #10).

This failure created the potential for patients to be discharged without addressing their physical needs, the appropriateness of the discharge plan and without the continuity of the plan of care post discharge.

FINDINGS

POLICY

According to the policy, Indwelling Urinary Catheter Insertion, Maintenance, Irrigation and Removal Procedures, after removal, monitor patient for incontinence, problems voiding, or any signs of infection.

According to the policy, Oxygen Protocol, the following objectives will be utilized in the determination of appropriateness of oxygen therapy, SaO2/SpO2 less than 90%. When the SaO2 is borderline with the patient breathing room air, 89-90%, the patient will be ambulated to determine oxygen requirements with activity, unless contraindicated. Portable oxygen is suggested if indicated.

According to the policy, Chain of Command, employees shall follow proper communication channels to assure appropriate delivery of safe, effective patient care. After alerting department director or manager/designee of physician non-response, contact as appropriate the following order until medical staff care/assistance is available: Attending or partner covering, Nursing supervisor, department chair, Medical staff president, Chief medical officer or designee. Complete an occurrence report of all incidents of non-response.

According to the policy, Discharge Planning, all patients and his/her significant others will be ensured appropriate, effective discharge plans while using proper utilization of resources. All patients are provided discharge instructions regardless of their post discharge placement setting. The patient's nurse is responsible for coordinating routine patient discharges and making referrals to appropriate ancillary services. For patients not initially identified as in need of a discharge plan, changes in the patient condition may then warrant a discharge planning evaluation. Continual case management, nursing, ancillary, and physician assessments through the patient's stay prompts adjustments to the discharge plan. The discharge plan includes knowledge necessary for the patient and/or family to meet ongoing healthcare needs. The discharge summary, written by the physician, includes the following: the reason for hospitalization, significant findings, procedures performed and care, treatment, and services provided, patient's condition at discharge, information given to the patient and family as appropriate.

REFERENCES

According to the Rules & Regulations of the Medical Staff as approved by the Governing Board on April 22, 2003 and subsequently amended, the last amendment having been approved August 28, 2015, a discharge summary must be recorded for all patients.

According to, Algorithm for Bladder Scanning and Action Based on Results of Bladder Scan, the registered nurse (RN) will reassess within 6 hours after straight catheterization times one and notify attending physician if patient continues to have volume greater than 100 milliliters (ml), document process and physician direction in the medical record.

1. The facility failed to assess whether Patient #3 required home oxygen to be ordered upon discharge from the facility.

a) Record review revealed Patient #3 was admitted on 07/28/17 for spinal surgery and discharged 4 days later on 07/31/17. The patient's history showed no documentation of oxygen use at home.

According to the respiratory charges, Patient #3 received oxygen on 07/28/17, 07/29/17 and again on 07/30/17.

According to the pulse oximetry (pulse ox) readings for Patient #3, on 07/29/17 from 4:48 a.m. until 5:00 a.m., the patient's pulse ox reading remained at 84-85%.

According to the pulse ox reading on 07/30/17 from 4:39 a.m. until 4:45 a.m., the patient's pulse ox reading remained at 82%-85%.

According the vital sign record on 07/31/17 at 7:52 a.m., the patient's pulse ox reading was 89% while on room air (RA). The patient was discharged at 3:19 p.m. without an evaluation to determine in home oxygen was required.

b) On 10/25/17 at 3:58 p.m., an interview was conducted with Registered Nurse Manager (RN) #3 who had oversight of nursing staff at the facility and had been assigned to care for Patient #3. RN #3 confirmed no further interventions related to the patient's pulse ox status were documented. This was in direct contrast to facility policy which stated oxygen was a prescribed drug and a pulse ox of less than 90% would be utilized in the determination of the appropriateness of oxygen therapy.

c) On 10/26/17 at 10:54 a.m., an interview was conducted with RN #4, who stated s/he worked as a Charge Nurse on the unit Patient #3 was hospitalized on. After review of Patient #3's pulse ox on 07/31/17 at 7:52 a.m. with a reading of 89%, RN #4 stated the expectation would be to notify the physician and have the patient ambulate on room air to test for de-saturation (a decrease in oxygenation). RN #4 stated there was no documentation of either in the patient's medical record.

d) On 10/25/17 at 2:16 p.m., a joint interview was conducted with Respiratory therapist (RT) #1 and RT #2. A review of Patient #3's chart was completed and RT #1 confirmed Patient #3 received oxygen for 3 nights, from 07/28/17 - 07/30/17 while hospitalized.

After a review of Patient #3's pulse ox readings for 07/29/17 and 07/30/17, RT #1 stated Patient #3 should have had home oxygen (O2) therapy ordered and confirmed the patient had no orders for home O2. RT #1 stated oxygenation was important as it provided air to the lungs and heart and then the rest of the body and was vital to preserving the patient's brain tissue.

e) On 10/26/17 at 9:07 a.m., an interview was conducted with Physician #6, who had provided care for Patient #3 during the hospitalization. Physician #6 stated if a patient's pulse ox was below 88% the patient would possibly require home oxygen. Physician #6 stated s/he would have expected to receive a phone call to discuss the patient's pulse ox.

2. The facility failed to ensure Patient #3 was safe to be discharged from the facility upon removing his/her foley catheter.

a) On review of Patient #3's medical record, a foley catheter (flexible tube placed through the urethra and into the bladder to drain urine) was placed on 07/28/17 at 12:50 p.m. and removed on 07/31/17 at 12:56 p.m. There was no further documentation the patient was monitored or urinated after the foley catheter was removed and prior to his/her discharge. Furthermore, there was no documentation the patient or family was instructed on post foley monitoring or signs and symptoms of complications.

b) On 10/25/17 at 3:58 p.m., an interview was conducted with RN #3 who confirmed removing the patient's foley catheter and discharging the patient. RN #3 confirmed there was no documentation the patient urinated after the foley catheter was removed and no documentation the patient or family was instructed on post foley monitoring or signs and symptoms of complications. RN #3 stated it was physician preference whether a patient would stay at the facility to be monitored after the foley catheter was removed and stated patients had been sent home before without monitoring. This was in direct contrast to facility policy.

RN #3 stated the risks of not urinating after foley catheter removal would be the patient's bladder would continue to fill with the bladder overstretched and could lead to damage.

c) On 10/26/17 at 10:54 a.m., an interview was conducted with RN #4 who stated the expectation after removal of a foley was to verify the patient urinated. RN #4 stated it was important to verify post foley removal, due to the potential of urinary retention and infection, which was hospital policy. On review of Patient #3's medical record, RN #4 stated there was no documentation Patient #3 urinated after the removal of the foley and prior to discharge.

d) On 10/26/17 at 9:07 a.m., an interview was conducted with Physician #6 who stated the expectation for all patients after foley removal would be to monitor the patient and verify the patient urinated. Physician #6 stated if there was no urination s/he expected staff to follow hospital protocol for bladder scanning.

3. The facility failed to ensure Patient #3 was discharged in a timely manner.

a) Review of Patient #3's medical record revealed on 07/30/17 an orthopedic surgery note stated the Patient #3 may discharge home if cleared by medicine.

On 07/30/17 at 2:46 p.m. a Nursing Note stated a call to the medicine physician was attempted twice to discuss possible patient discharge today with no answer.

On further review of Patient #3's medical record there was no further documentation in the medical record documenting another physician was contacted to clear the patient for discharge. This was in direct contrast to the facilities chain of command policy which stated if unable to contact a physician the next person to contact would be the nursing supervisor.

b) On 10/26/17 at 9:42 a.m., an interview was conducted with RN #5 who stated s/he had attempted to contact Physician #6 on 07/30/17 with no answer. RN #5 stated Physician #6 worked alone and there would not have been anyone else to contact to discharge the patient. RN #5 was unaware of the facility's chain of command policy.

c) On 10/26/17 at 10:54 a.m. an interview was conducted with Charge RN # 4. On review of Patient #3's medical record RN #4 confirmed Patient #3 was held awaiting Physician #6's medical clearance for discharge.

d) On 10/26/17 at 9:07 a.m., an interview was conducted with Physician #6 who had provided care for Patient #3. Physician #6 stated Patient #3 had been cleared for discharge by him/her on 07/30/17 but stated the medical record lacked the appropriate documentation of medicine clearance for discharge.

4. The facility failed to ensure a discharge summary was recorded for all patients.

a) Review of Patient #3's medical record revealed s/he was admitted on 07/28/17 for spinal surgery. The patient was admitted to the facility for a total of 4 days and was discharged on 07/31/17. On review of Patient #3's medical record, no discharge summary was noted.

Review of Patient # 7's medical record revealed s/he was admitted on 09/29/17 for spinal surgery. The patient was admitted to the facility for a total of 4 days and was discharged on 10/02/17. On review of Patient #7's medical record, no discharge summary was noted.

Review of Patient #10's medical record revealed s/he was admitted on 04/04/17 for hip surgery. The patient was admitted to the facility for a total of 2 days and was discharged on 04/06/17. On review of Patient #10's medical record, no discharge summary was noted.

b) On 10/26/17 at 12:04 p.m., an interview was conducted with the Chief Medical Officer (CMO #7). On review of Patients #3, #7 and #10's medical records, CMO #7 confirmed all three medical records lacked a discharge summary as required by policy.

CMO #7 stated the importance of the discharge summary was to summarize the care provided to the patient during their stay at the facility and was a way to provide continuity of care for the patient to be used by external facilities. CMO #7 stated the discharge summary included a summary of the care provided along with any medications and medication updates for the patient. CMO #7 stated s/he was unsure why a discharge summary had not been completed for the 3 patients.