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Based on record review of 1 of 8 patient records (Patient 3), staff interview and review of Quality/Performance Improvement Plan and Quality Assurance (QA) data regarding patient readmission, the facility failed to assess/collect data to capture failed discharge planning in time to protect patients from further readmissions. Patient 3, an Oxygen dependent patient, was discharged on 4/9/16 to home without an assessment of her home Oxygen needs, discharge instructions failed to include Oxygen usage and failure to ensure the supplier of home Oxygen could meet her needs. The Patient was readmitted 4/10/16 with hypoxia (low Oxygen) directly related to the failure of the discharge planning to ensure the patient's needs could be met. This failure was not identified by the facility until record reviews were completed of Patient 3's record during the survey on 5/25/16. Prior to 5/26/16 the facility was doing a 30 day retrospective review on readmissions. A retrospective review 30 days later on readmissions does not provide a means for the facility to identify adverse outcomes and implement corrective actions to prevent further readmissions. This failure resulted in the facility being found out of compliance on 5/26/16 with the Condition of Participation for Discharge Planning and being cited at Immediate Jeopardy to the health and safety of patients. Failure to provide an effective QA program to identify facility problems and opportunities to improve care/reduce negative outcomes has the potential to affect all patients in the facility. The facility census was 79. Findings are: See also A 0799.

A. Record review of the facility QA plan titled "Quality/Performance Improvement Plan 2016" Under the section titled "Statement of Purpose" the plan states that the plan is "designed to reduce factors that contribute to unanticipated adverse events and/or outcomes." The plan identifies data collection will be "relevant, timely accurate and complete."

Record review of QA data on the document titled "2016 Great Plains Health Balanced Score Card" identifies for the first quarter the 30 day readmission rate was 12.34%. This was higher than the facility identified goals. The facility "Stretch Goal" was 10 % and the "Accepted Ntl [National] Standard" was identified as 12%. The first quarter of 2016 identified zero 30 day readmissions related to COPD. However in 2015 the highest number of 30 day readmissions were from COPD at 31.7 % well above the Accepted National Standard rate of 20.2 % or the facility Stretch Goal of 18 %.

B. Interview with the Quality Assurance Director on 5/26/16 at 9:00 AM revealed the facility was doing a 100% review of 30 day readmissions. The reviews were done on a retrospective basis 30 days after the month of the readmission. Patient 3's failure of the discharge plan to meet the needs of the patient resulting in readmission the next day related to the COPD diagnosis and hypoxia (low oxygen) level had not yet been reviewed by the hospital.

C. Electronic Medical Record Review (EMR) of Patient 3"s record identified as "3 a" revealed the patient was admitted on 4/6/16 to the Intensive Care Unit (ICU) from the Emergency Department (ED). Diagnosis included COPD (Chronic Obstructive Pulmonary Disease), hypoxia, hyponatremia (low salt content in the blood) and urinary tract infection. Review of the Case Management Assessment documentation on 4/7/16 noted the patient needed Discharge Planning Services and was identified as 'high risk screening; ICU'. Discharge Planning Notes 4/7/16 at 10:30 AM by CM "A" (Case Manager) notes the Area Agency on Aging (AAA) was contacted. The notes state the patient has no family, lives alone and the friend has concerns of self-neglect. The On 4/8/16 at 2:28 PM CM A spoke with the patient and the friend regarding the home environment. The patient told the CM that Oxygen (O 2) is worn when not smoking. The CM informed the patient that the AAA will be in contact with her Monday 4/11/16. The patient denied any further CM needs and said discharge will be tomorrow 4/9/16 (Saturday). The record has no further CM notes. The CM notes do identify the patient is on Oxygen at home but do not identify an assessment of home Oxygen needs at discharge or supplier availability.

O 2 orders on admission 4/6/16 at 6:32 PM by Medical Doctor (MD) B state Respiratory Therapy (RT) is to implement the Oximetry Protocol. The order is identified as ongoing. If SpO2 [Oxygen saturation in the blood] is less than 89% oxygen is applied and adjusted to keep the SpO2 greater than or equal to 89%. The order further states that patients who use oxygen at home will be kept at their prescribed oxygen level or greater to keep SpO2 greater than or equal to 89 %. Normal SpO2 levels are 95 -100 % with hypoxia defined as less than 90%. The orders also included aerosol Duo Neb treatments every 6 hours to be given every 6 hours by respiratory Therapy (RT). The aerosol Duo -Neb treatments relax and open the airways to help facilitate breathing.


Record review of RT documentation revealed the patient was requiring continuous O 2 during the entire hospital stay. The patient was on BiPap on 4/6 and 4/7/16 with an O 2 level of 35%. Room air is 21 %. BiPap is a non invasive mechanical pressure support ventilation system that is delivered by mask and reduces the work of breathing by delivering O 2 between 2 different levels of positive airway pressure. Oxygen by mask or nasal cannula was delivered between 2 - 6 liters per minute to maintain SpO2 levels greater than 89% on 4/8 and 4/9/16. On 4/8/16 RT notes at 6:33 PM that the patient was on O 2 at 3 liters/minute and that "this is home O 2 level as well." The SpO2 was 90 % at that time. Review of Vital Sign Flowsheet on 4/9/16 noted that O 2 was at 4 liters per minute by nasal cannula since 3:20 AM. The last vital signs recorded were at 7:03 AM with Oxygen at 4 liters/ minute and SpO2 at 92%. The RT documentation during the stay failed to identify the patient's oxygen needs at discharge or any assessment of how those needs would be met.


Review of discharge instructions 4/9/16 included the aerosol Duo-Neb respiratory treatments every 6 hours as needed for shortness of breath. Neither the medications (Oxygen is a medication) discharge list or written instructions mention the use of Oxygen. The patient signed the instructions indicating they were received and understood. Patient 3 discharged to home at 1:08 PM on Saturday 4/9/16 accompanied by her friend.

D. EMR review of Patient 3's readmission record identified as "3 b" revealed the patient arrived by rescue squad to the ED on Sunday 4/10/16 at 7:00 PM (20 hrs and 52 minutes after discharge). The ED nurses documentation at 7:24 PM notes that Patient 3 just discharged from ICU yesterday for COPD exacerbation [flare up] and was told to wear O 2 at home but "her [oxygen] cord doesn't reach into the living room so she wasn't wearing any when EMS [Emergency Medical Service] arrived, O 2 on their arrival was 77 % on RA [room air]. 77% SpO2 is severely hypoxic (low).


Review of the History and Physical by the attending physician on 4/10/16 at 10:13 PM revealed the patient told the physician that at home normally 2 liters of Oxygen are needed. The patient was continuing to have shortness of breath at rest despite wearing the Oxygen. The patient also stated severe wheezing was present. The patient "called the Oxygen company to increase her Oxygen level but they were not available until Monday (4/11/16)." The patient also admitted "trouble understanding her new medications." Today while in the kitchen the patient tripped and hit her right knee. The neighbor saw this and called 911. On arrival she was wheezing, short of breath and hypoxic at 77%. During the exam the patient was on Oxygen with a saturation level of 90 %. The patient was alert and oriented. The patient was readmitted with diagnosis of acute dyspnea (difficult breathing), acute exacerbation of COPD, Hyponatremia, Single abrasion to right knee and hypoxia. After readmission, patient was in the hospital until discharge to an Assisted Living Facility on 4/16/16 (6 days later).

Based on record review of 1 of 8 patient records (Patient 3), staff interview and review of Quality/Performance Improvement Plan and Quality Assurance (QA) data regarding patient readmission, the facility failed to assess/collect data to capture failed discharge planning in time to protect patients from further readmissions. Patient 3, an Oxygen dependent patient, was discharged on 4/9/16 to home without an assessment of her home Oxygen needs, discharge instructions failed to include Oxygen usage and failure to ensure the supplier of home Oxygen could meet her needs. The Patient was readmitted 4/10/16 with hypoxia (low Oxygen) directly related to the failure of the discharge planning to ensure the patient's needs could be met. The patient had a 6 day hospital stay with the readmission. This adverse event was not identified by the facility until record reviews were completed of Patient 3's record during the survey on 5/25/16. Prior to 5/26/16 the facility was doing a 30 day retrospective review on readmissions. A retrospective review 30 days later on readmissions does not provide a means for the facility to identify adverse outcomes and implement corrective actions to prevent further readmissions. This failure resulted in the facility being found out of compliance on 5/26/16 with the Condition of Participation for Discharge Planning and being cited at Immediate Jeopardy to the health and safety of patients. Failure to track/analyze for causal factors related to adverse events soon after the occurrence results in missed opportunities to improve care/reduce negative outcomes. This has the potential to affect all patients in the facility. The facility census was 79.

Findings are: See also A 0799.

A. Record review of the facility QA plan titled "Quality/Performance Improvement Plan 2016" Under the section titled "Statement of Purpose" the plan states that the plan is "designed to reduce factors that contribute to unanticipated adverse events and/or outcomes." The plan identifies data collection will be "relevant, timely accurate and complete."


Record review of QA data on the document titled "2016 Great Plains Health Balanced Score Card" identifies for the first quarter the 30 day readmission rate was 12.34%. This was higher than the facility identified goals. The facility "Stretch Goal" was 10 % and the "Accepted Ntl [National] Standard" was identified as 12%. The first quarter of 2016 identified zero 30 day readmissions related to COPD. However in 2015 the highest number of 30 day readmissions were from COPD at 31.7 % well above the Accepted National Standard rate of 20.2 % or the facility Stretch Goal of 18 %.

B. Interview with the Quality Assurance Director on 5/26/16 at 9:00 AM revealed the facility was doing a 100% review of 30 day readmissions. The reviews were done on a retrospective basis 30 days after the month of the readmission. Patient 3's failure of the discharge plan to meet the needs of the patient resulting in readmission the next day related to the COPD diagnosis and hypoxia (low oxygen) level had not yet been reviewed by the hospital.

C. Electronic Medical Record Review (EMR) of Patient 3"s record identified as "3 a" revealed the patient was admitted on 4/6/16 to the Intensive Care Unit (ICU) from the Emergency Department (ED). Diagnosis included COPD (Chronic Obstructive Pulmonary Disease), hypoxia, hyponatremia (low salt content in the blood) and urinary tract infection. Review of the Case Management Assessment documentation on 4/7/16 noted the patient needed Discharge Planning Services and was identified as 'high risk screening; ICU'. Discharge Planning Notes 4/7/16 at 10:30 AM by CM "A" (Case Manager) notes the Area Agency on Aging (AAA) was contacted. The notes state the patient has no family, lives alone and the friend has concerns of self-neglect. The On 4/8/16 at 2:28 PM CM A spoke with the patient and the friend regarding the home environment. The patient told the CM that Oxygen (O 2) is worn when not smoking. The CM informed the patient that the AAA will be in contact on with her Monday 4/11/16. The patient denied any further CM needs and said discharge will be tomorrow 4/9/16 (Saturday). The record has no further CM notes. The CM notes do identify the patient is on Oxygen at home but do not identify an assessment of home Oxygen needs at discharge or supplier availability.


O 2 orders on admission 4/6/16 at 6:32 PM by Medical Doctor (MD) B state Respiratory Therapy (RT) is to implement the Oximetry Protocol. The order is identified as ongoing. If SpO2 [Oxygen saturation in the blood] is less than 89% oxygen is applied and adjusted to keep the SpO2 greater than or equal to 89%. The order further states that patients who use oxygen at home will be kept at their prescribed oxygen level or greater to keep SpO2 greater than or equal to 89 %. Normal SpO2 levels are 95 -100 % with hypoxia defined as less than 90%. The orders also included aerosol Duo Neb treatments every 6 hours to be given every 6 hours by RT. The aerosol Duo -Neb treatments relax and open the airways to help facilitate breathing.


Record review of RT documentation revealed the patient was requiring continuous O 2 during the entire hospital stay. The patient was on BiPap on 4/6 and 4/7/16 with an O 2 level of 35%. Room air is 21 %. BiPap is a non invasive mechanical pressure support ventilation system that is delivered by mask and reduces the work of breathing by delivering O 2 between 2 different levels of positive airway pressure. Oxygen by mask or nasal cannula was delivered between 2 - 6 liters per minute to maintain SpO2 levels greater than 89% on 4/8 and 4/9/16. On 4/8/16 RT notes at 6:33 PM that the patient was on O 2 at 3 liters/minute and that "this is home O 2 level as well." The SpO2 was 90 % at that time. Review of Vital Sign Flowsheet on 4/9/16 noted that O 2 was at 4 liters per minute by nasal cannula since 3:20 AM. The last vital signs recorded were at 7:03 AM with Oxygen at 4 liters/ minute and SpO2 at 92%. The RT documentation during the stay failed to identify the patient's oxygen needs at discharge or any assessment of how those needs would be met.


Review of discharge instructions 4/9/16 included the aerosol Duo-Neb respiratory treatments every 6 hours as needed for shortness of breath. Neither the medications (Oxygen is a medication) discharge list or written instructions mention the use of Oxygen. The patient signed the instructions indicating they were received and understood. Patient 3 discharged to home at 1:08 PM on Saturday 4/9/16 accompanied by her friend.

D. EMR review of Patient 3's readmission record identified as "3 b" revealed the patient arrived by rescue squad to the ED on Sunday 4/10/16 at 7:00 PM (20 hrs and 52 minutes after discharge). The ED nurses documentation at 7:24 PM notes that Patient 3 just discharged from ICU yesterday for COPD exacerbation [flare up] and was told to wear O 2 at home but "her [oxygen] cord doesn't reach into the living room so she wasn't wearing any when EMS [Emergency Medical Service] arrived, O 2 on their arrival was 77 % on RA [room air]. 77% SpO2 is severely hypoxic (low).


Review of the History and Physical by the attending physician on 4/10/16 at 10:13 PM revealed the patient told the physician that at home normally 2 liters of Oxygen are needed. The patient was continuing to have shortness of breath at rest despite wearing the Oxygen. The patient also stated severe wheezing was present. The patient "called the Oxygen company to increase her Oxygen level but they were not available until Monday (4/11/16)." The patient also admitted "trouble understanding her new medications." Today while in the kitchen the patient tripped and hit her right knee. The neighbor saw this and called 911. On arrival she was wheezing, short of breath and hypoxic at 77%. During the exam the patient was on Oxygen with a saturation level of 90 %. The patient was alert and oriented. The patient was readmitted with diagnosis of acute dyspnea (difficult breathing), acute exacerbation of COPD, Hyponatremia, Single abrasion to right knee and hypoxia. The patient was in the hospital until discharge to an Assisted Living Facility on 4/16/16 (6 days later).

Based on patient Electronic Medical Record (EMR) review, facility discharge planning policy review, physician and staff interviews the facility failed to ensure 1 of 8 sampled patients (Patient 3) received discharge planning services to meet their needs and to ensure the initial implementation of the discharge plan. The facility failed to evaluate the discharge planning need for home oxygen prior to discharge. Staff failed to get physician orders for oxygen at discharge when the patient was oxygen dependent, or to include the use of oxygen in written discharge instructions given to the patient on 4/9/16 prior to discharge to home. This failure resulted in the patient's emergency readmission for severe hypoxia (low oxygen) 29 hours and 52 minutes after discharge to home. Failure to meet the patient's discharge planning needs for oxygen places all patients discharging on oxygen at risk for hypoxia or death. The facility provided data that an average of 6 -7 oxygen dependent patients have discharged per month for the past 3 months. After conferring with CMS (Centers for Medicare & Medicaid Services) the facility was determined to have Immediate Jeopardy (IJ) conditions related to non compliance with Condition of Participation for Discharge Planning. IJ conditions have existed since 4/9/16 (discharge date of Patient 3). The administrator was notified of the determination of IJ on 5/26/16 at 4:16 PM. The facility was able to implement an action plan on 5/25/16 to address the non compliance upon review of Patient 3 's EMR. The facility action plan review and verification of implementation on 5/26/16 resulted in the abatement of the IJ conditions per CMS. The total facility census was 79.

Findings are:

A. EMR of Patient 3"s record identified as "3 a" revealed the patient was admitted on 4/6/16 to the Intensive Care Unit (ICU) from the Emergency Department (ED). Diagnosis included COPD (Chronic Obstructive Pulmonary Disease), hypoxia, hyponatremia (low salt content in the blood) and urinary tract infection. Review of the Case Management Assessment documentation on 4/7/16 noted the patient needed Discharge Planning Services and was identified as 'high risk screening; ICU'. Discharge Planning Notes 4/7/16 at 10:30 AM by CM "A" (Case Manager) notes the Area Agency on Aging (AAA) was contacted. The notes state the patient has no family, lives alone and the friend has concerns of self-neglect. The On 4/8/16 at 2:28 PM CM A spoke with the patient and the friend regarding the home environment. The patient told the CM that Oxygen (O 2) is worn when not smoking. The CM informed the patient that the AAA will be in contact on with her Monday 4/11/16. The patient denied any further CM needs and said discharge will be tomorrow 4/9/16 (Saturday). The record has no further CM notes. The CM notes do identify the patient is on Oxygen at home but do not identify an assessment of home Oxygen needs at discharge or supplier availability.


O 2 orders on admission 4/6/16 at 6:32 PM by Medical Doctor (MD) B state Respiratory Therapy (RT) is to implement the Oximetry Protocol. The order is identified as ongoing. If SpO2 [Oxygen saturation in the blood] is less than 89% oxygen is applied and adjusted to keep the SpO2 greater than or equal to 89%. The order further states that patients who use oxygen at home will be kept at their prescribed oxygen level or greater to keep SpO2 greater than or equal to 89 %. Normal SpO2 levels are 95 -100 % with hypoxia defined as less than 90%. The orders also included aerosol Duo Neb treatments every 6 hours to be given every 6 hours by RT. The aerosol Duo -Neb treatments relax and open the airways to help facilitate breathing.


Record review of RT documentation revealed the patient was requiring continuous O 2 during the entire hospital stay. The patient was on BiPap on 4/6 and 4/7/16 with an O 2 level of 35%. Room air is 21 %. BiPap is a non invasive mechanical pressure support ventilation system that is delivered by mask and reduces the work of breathing by delivering O 2 between 2 different levels of positive airway pressure. Oxygen by mask or nasal cannula was delivered between 2 - 6 liters per minute to maintain SpO2 levels greater than 89% on 4/8 and 4/9/16. On 4/8/16 RT notes at 6:33 PM that the patient was on O 2 at 3 liters/minute and that "this is home O 2 level as well." The SpO2 was 90 % at that time. Review of Vital Sign Flowsheet on 4/9/16 noted that O 2 was at 4 liters per minute by nasal cannula since 3:20 AM. The last vital signs recorded were at 7:03 AM with Oxygen at 4 liters/ minute and SpO2 at 92%. The RT documentation during the stay failed to identify the patient's oxygen needs at discharge or any assessment of how those needs would be met.


Review of discharge instructions 4/9/16 included the aerosol Duo-Neb respiratory treatments every 6 hours as needed for shortness of breath. Neither the medications (Oxygen is a medication) discharge list or written instructions mention the use of Oxygen. The patient signed the instructions indicating they were received and understood. Patient 3 discharged to home at 1:08 PM on Saturday 4/9/16 accompanied by her friend.

B. EMR review of Patient 3's readmission record identified as "3 b" revealed the patient arrived by rescue squad to the ED on Sunday 4/10/16 at 7:00 PM (20 hrs and 52 minutes after discharge). The ED nurses documentation at 7:24 PM notes that Patient 3 just discharged from ICU yesterday for COPD exacerbation [flare up] and was told to wear O 2 at home but "her [oxygen] cord doesn't reach into the living room so she wasn't wearing any when EMS [Emergency Medical Service] arrived, O 2 on their arrival was 77 % on RA [room air]. 77% SpO2 is severely hypoxic (low).


Review of the History and Physical by the attending physician on 4/10/16 at 10:13 PM revealed the patient told the physician that at home normally 2 liters of Oxygen are needed. The patient was continuing to have shortness of breath at rest despite wearing the Oxygen. The patient also stated severe wheezing was present. The patient "called the Oxygen company to increase her Oxygen level but they were not available until Monday (4/11/16)." The patient also admitted "trouble understanding her new medications." Today while in the kitchen the patient tripped and hit her right knee. The neighbor saw this and called 911. On arrival she was wheezing, short of breath and hypoxic at 77%. During the exam the patient was on Oxygen with a saturation level of 90 %. The patient was alert and oriented. The patient was readmitted with diagnosis of acute dyspnea (difficult breathing), acute exacerbation of COPD, Hyponatremia, Single abrasion to right knee and hypoxia. The patient was in the hospital until discharge to an Assisted Living Facility on 4/16/16 (6 days later).

C. Record review of facility policy titled "Discharge Planning" with effective date of 04/90 identifies the policy is to "optimize compliance with the patient's post hospital plan of care." The policy states "High risk criteria for discharge planning is used to help identify patients that have complex needs and/or at risk for readmission requiring a higher level of discharge planning/coordination of care." Patient 3 was identified as being high risk on admission. The policy identifies the "collaboration with other members of the health care team to evaluate the type of after-care needed." The policy also states "All disciplines are asked to assess and document information that will help identify areas of special risk to the patient. Interdisciplinary team meetings are held daily, Monday through Friday to discuss discharge planning needs. An interdisciplinary team evaluates the discharge plan and documentation is completed in the EMR under Case Management." The policy identifies the regular members of the interdisciplinary team include Case Management, Utilization Review, Physical/Occupational Therapist, Dietician, Pharmacy, Respiratory Therapy, the designee from each nursing unit, and any other members as necessary to include all aspects of care. Under the section titled "Anticipated needs/services:" The policy identifies staff are to discuss with the physician the discharge plan and obtain orders if needed. There were no orders for Oxygen at discharge for Patient 3. Staff are to ascertain that the patient has follow-up care at discharge, assess if community resources should be contacted and contact appropriate personnel. Assess the availability of community or other healthcare resources to assist with care including the need for special equipment, supplies or medication.


Record review of facility policy titled "Ordering Home Therapy" effective date 7/92 identifies that Cardiopulmonary Services staff will "assist in the continuum of care for the patient from hospital to home." Upon physician order the RT staff 'will assist with making arrangements for, and in some cases, providing instruction to the patient on proper use of equipment that has been ordered for the patient to use at home." Under the section titled "Procedure" the policy states that "Should it be determined that a patient will require home oxygen, a home equipment evaluation will be performed to assess the needs of the patient."

D. Interview with MD B on 5/26/16 at 1:00 PM revealed the physician was aware the patient was Oxygen dependent at home. MD B stated regarding the discharge on 4/9/16 that "it was my intent to send her home on O 2 therapy." Normally "if a patient is O 2 dependent Respiratory Therapy checks them and assesses their needs before discharge."

E. Staff interview with the Director of Cardiopulmonary Services on 5/25/16 at 3:50 PM confirmed Patient 3's medical record for 4/6-4/9/16 hospital stay did not contain any documentation of RT staff ensuring the patient had an adequate O 2 supply at home or O 2 orders at discharge. The Director confirmed the patient was Oxygen dependent. The Director stated the evaluation for RT needs would have included if the patient has O 2, tubing to reach all areas and a portable source for visiting but that this was not done in this case.


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F. An action plan was developed by the hospital on 5/25/2016 with initial implementation on 5/25/2016. The action plan was presented to the survey team at 9:00 AM on 5/26/2016 by the administrative staff. The Administrator stated the action plan was developed to remedy the incident of failure to develop and implement a safe and appropriate discharge plan for sampled patient 3. Their action plan to correct the deficiencies included:

1. The nursing assessment/reassessment policy was revised to include a "mandatory screen" in the EMR for home respiratory medical equipment. Survey team verified the "Screen" was already in the EMR and nursing staff cannot move on through the assessment until it is completed.

2. Nursing education related to step 1 above. Education started prior to start of Day Shift on 5/26/2016. Survey team verified by reviewing the education information, the first sign-in sheets and interviews of nursing staff who verified receiving the training that morning. This will be ongoing until all nursing staff have received the training.

3. Development of an assessment check list to be done at discharge for respiratory care needs of patients requiring respiratory cares. Survey staff verified by reviewing the check list provided by the facility.

4. Education provided to Respiratory Therapy [RT] staff one on one regarding the assessments and check list to be done for discharge plans. A post test was developed. The education and testing was initiated on 5/25/2016. Survey team verified the training and obtained copies of the post test for all RT staff in the department. All RT staff were able to pass the post test that included a scenario situation.

5. Oxygen is considered a medication. The facility added Oxygen to the electronic Medication Administration Record [MAR] system to assure when Oxygen is ordered by the patient's provider it will be listed on the MAR requiring that it be signed off on each shift that oxygen is being administered to the patient. The IT staff had already added the change to the electronic system. Survey staff were able to verify through medical record review and interviews of 2 patients being discharged requiring home oxygen therapy on 5/26/2016.


6. The Quality Department developed a concurrent root cause analysis audit tool of causal factors to be completed on 100% of all inpatients readmitted within 30 days. The results will be reported on a monthly basis to the Clinical Operations Team and monthly to the Quality Board Committee. Survey staff verified by review of the audit tool and interview with the Director of Quality Department.


7. The administrative team developing the action plan identified and reviewed the medical records of the inpatients who had been discharged and had received oxygen therapy during their inpatient stay for the 10 days prior to 5/25/2016. The identified inpatients were contacted by phone during the evening of 5/25/2016 to determine if they had adequate supplies, education and treatment since discharge. Survey staff verified by the review of information provided by the hospital.


8. An audit tool was being created to assure 100% compliance with the concurrent root cause analysis for readmission. Survey staff verified by review of the tool provided by the hospital.


9. Development and addition to the Discharge Planning policy and procedure of a discharge checklist to be completed prior to inpatient discharge. Survey staff verified the checklist had been developed.


10. The Respiratory Therapy department staff will complete a 100% concurrent check daily to ensure the respiratory assessment had been completed. The audits will continue for 6 months and then be evaluated for further implementation. Survey Staff verified by review of the audit tool and observation of the Director of Respiratory Therapy completing an audit tool.


11. Results of all audit tools will be reported to the Clinical Operations Team and the Senior Leadership/Executive Team monthly.

The action plan was verified as having been implemented and actively in progress by the survey team. This information was reviewed with CMS. CMS responded that the action plan was sufficient to abate the immediate jeopardy situation on 5/26/2016. The Administrator was informed of the abatement on 5/26/2016.

Based on patient Electronic Medical Record (EMR) review, facility discharge planning policy review, physician and staff interviews the facility failed to ensure 1 of 8 sampled patients (Patient 3) received discharge planning services to include an evaluation of the post hospital Oxygen needs of the patient and the availability of Oxygen and necessary respiratory equipment in the home to meet their needs. Patient 3 was Oxygen dependent. This failure resulted in the patient's emergency readmission for severe hypoxia (low oxygen) 29 hours and 52 minutes after discharge to home. Failure to meet the patient's discharge planning needs for oxygen places all patients discharging on oxygen at risk for hypoxia or death. The facility provided data that an average of 6 -7 oxygen dependent patients have discharged per month for the past 3 month The total facility census was 79.

Findings are:

A. EMR of Patient 3"s record identified as "3 a" revealed the patient was admitted on 4/6/16 to the Intensive Care Unit (ICU) from the Emergency Department (ED). Diagnosis included COPD (Chronic Obstructive Pulmonary Disease), hypoxia, hyponatremia (low salt content in the blood) and urinary tract infection. Review of the Case Management Assessment documentation on 4/7/16 noted the patient needed Discharge Planning Services and was identified as 'high risk screening; ICU'. Discharge Planning Notes 4/7/16 at 10:30 AM by CM "A" (Case Manager) notes the Area Agency on Aging (AAA) was contacted. The notes state the patient has no family, lives alone and the friend has concerns of self-neglect. The On 4/8/16 at 2:28 PM CM A spoke with the patient and the friend regarding the home environment. The patient told the CM that Oxygen (O 2) is worn when not smoking. The CM informed the patient that the AAA will be in contact on with her Monday 4/11/16. The patient denied any further CM needs and said discharge will be tomorrow 4/9/16 (Saturday). The record has no further CM notes. The CM notes do identify the patient is on Oxygen at home but do not identify an assessment of home Oxygen needs at discharge or supplier availability.


O 2 orders on admission 4/6/16 at 6:32 PM by Medical Doctor (MD) B state Respiratory Therapy (RT) is to implement the Oximetry Protocol. The order is identified as ongoing. If SpO2 [Oxygen saturation in the blood] is less than 89% oxygen is applied and adjusted to keep the SpO2 greater than or equal to 89%. The order further states that patients who use oxygen at home will be kept at their prescribed oxygen level or greater to keep SpO2 greater than or equal to 89 %. Normal SpO2 levels are 95 -100 % with hypoxia defined as less than 90%. The orders also included aerosol Duo Neb treatments every 6 hours to be given every 6 hours by RT. The aerosol Duo -Neb treatments relax and open the airways to help facilitate breathing.


Record review of RT documentation revealed the patient was requiring continuous O 2 during the entire hospital stay. The patient was on BiPap on 4/6 and 4/7/16 with an O 2 level of 35%. Room air is 21 %. BiPap is a non invasive mechanical pressure support ventilation system that is delivered by mask and reduces the work of breathing by delivering O 2 between 2 different levels of positive airway pressure. Oxygen by mask or nasal cannula was delivered between 2 - 6 liters per minute to maintain SpO2 levels greater than 89% on 4/8 and 4/9/16. On 4/8/16 RT notes at 6:33 PM that the patient was on O 2 at 3 liters/minute and that "this is home O 2 level as well." The SpO2 was 90 % at that time. Review of Vital Sign Flowsheet on 4/9/16 noted that O 2 was at 4 liters per minute by nasal cannula since 3:20 AM. The last vital signs recorded were at 7:03 AM with Oxygen at 4 liters/ minute and SpO2 at 92%. The RT documentation during the stay failed to identify the patient's oxygen needs at discharge or any assessment of how those needs would be met. There was no evidence the facility staff had discussed with the patient who the home Oxygen supplier she used was prior to admission or contact with the supplier to ensure the patient's current needs could be met. The patient discharged on 4/9/16 at 1:08 PM.

B. EMR review of Patient 3's readmission record identified as "3 b" revealed the patient arrived by rescue squad to the ED on Sunday 4/10/16 at 7:00 PM (20 hrs and 52 minutes after discharge). The ED nurses documentation at 7:24 PM notes that Patient 3 just discharged from ICU yesterday for COPD exacerbation [flare up] and was told to wear O 2 at home but "her [oxygen] cord doesn't reach into the living room so she wasn't wearing any when EMS [Emergency Medical Service] arrived, O 2 on their arrival was 77 % on RA [room air]. 77% SpO2 is severely hypoxic (low).


Review of the History and Physical by the attending physician on 4/10/16 at 10:13 PM revealed the patient told the physician that at home normally 2 liters of Oxygen are needed. The patient was continuing to have shortness of breath at rest despite wearing the Oxygen. The patient also stated severe wheezing was present. The patient "called the Oxygen company to increase her Oxygen level but they were not available until Monday (4/11/16)." The patient also admitted "trouble understanding her new medications." Today while in the kitchen the patient tripped and hit her right knee. The neighbor saw this and called 911. On arrival she was wheezing, short of breath and hypoxic at 77%. During the exam the patient was on Oxygen with a saturation level of 90 %. The patient was alert and oriented. The patient was readmitted with diagnosis of acute dyspnea (difficult breathing), acute exacerbation of COPD, Hyponatremia, Single abrasion to right knee and hypoxia. The patient was in the hospital until discharge to an Assisted Living Facility on 4/16/16 (6 days later).

C. Record review of facility policy titled "Discharge Planning" with effective date of 04/90 identifies the policy is to "optimize compliance with the patient's post hospital plan of care." The policy states "High risk criteria for discharge planning is used to help identify patients that have complex needs and/or at risk for readmission requiring a higher level of discharge planning/coordination of care." Patient 3 was identified as being high risk on admission. The policy identifies the "collaboration with other members of the health care team to evaluate the type of after-care needed." The policy also states "All disciplines are asked to assess and document information that will help identify areas of special risk to the patient. Interdisciplinary team meetings are held daily, Monday through Friday to discuss discharge planning needs. An interdisciplinary team evaluates the discharge pan and documentation is completed in the EMR under Case Management." The policy identifies the regular members of the interdisciplinary team include Case Management, Utilization Review, Physical/Occupational Therapist, Dietician, Pharmacy, Respiratory Therapy, the designee from each nursing unit, and any other members as necessary to include all aspects of care. Under the section titled "Anticipated needs/services:" The policy identifies staff are to discuss with the physician the discharge plan and obtain orders if needed. There were no orders for Oxygen at discharge for Patient 3. Staff are to ascertain that the patient has follow-up care at discharge, assess if community resources should be contacted and contact appropriate personnel. Assess the availability of community or other healthcare resources to assist with care including the need for special equipment, supplies or medication.

Record review of facility policy titled "Ordering Home Therapy" effective date 7/92 identifies that Cardiopulmonary Services staff will "assist in the continuum of care for the patient from hospital to home." Upon physician order the RT staff 'will assist with making arrangements for, and in some cases, providing instruction to the patient on proper use of equipment that has been ordered for the patient to use at home." Under the section titled "Procedure" the policy states that "Should it be determined that a patient will require home oxygen, a home equipment evaluation will be performed to assess the needs of the patient."

D. Interview with MD B on 5/26/16 at 1:00 PM revealed the physician was aware the patient was Oxygen dependent at home. MD B stated regarding the discharge on 4/9/16 that "it was my intent to send her home on O 2 therapy." Normally "if a patient is O 2 dependent Respiratory Therapy checks them and assesses their needs before discharge."

E. Staff interview with the Director of Cardiopulmonary Services on 5/25/16 at 3:50 PM confirmed Patient 3's medical record for 4/6-4/9/16 hospital stay did not contain any documentation of RT staff ensuring the patient had an adequate O 2 supply at home or O 2 orders at discharge. The Director confirmed the patient was Oxygen dependent. The Director stated the evaluation for RT needs would have included if the patient has O 2, tubing to reach all areas and a portable source for visiting but that this was not done in this case.

Based on patient Electronic Medical Record (EMR) review, facility discharge planning policy review, physician and staff interviews the facility failed to ensure 1 of 8 sampled patients (Patient 3) received discharge planning services to meet their needs and to ensure the initial implementation of the discharge plan. The facility failed to evaluate the discharge planning need for home oxygen prior to discharge. Staff failed to get physician orders for oxygen at discharge when the patient was oxygen dependent, or to include the use of oxygen in written discharge instructions given to the patient on 4/9/16 prior to discharge to home. This failure resulted in the patient's emergency readmission for severe hypoxia (low oxygen) 29 hours and 52 minutes after discharge to home. Failure to meet the patient's discharge planning needs for oxygen places all patients discharging on oxygen at risk for hypoxia or death. The facility provided data that an average of 6 -7 oxygen dependent patients have discharged per month for the past 3 months. The total facility census was 79.

Findings are:

A. EMR of Patient 3"s record identified as "3 a" revealed the patient was admitted on 4/6/16 to the Intensive Care Unit (ICU) from the Emergency Department (ED). Diagnosis included COPD (Chronic Obstructive Pulmonary Disease), hypoxia, hyponatremia (low salt content in the blood) and urinary tract infection. Review of the Case Management Assessment documentation on 4/7/16 noted the patient needed Discharge Planning Services and was identified as 'high risk screening; ICU'. Discharge Planning Notes 4/7/16 at 10:30 AM by CM "A" (Case Manager) notes the Area Agency on Aging (AAA) was contacted. The notes state the patient has no family, lives alone and the friend has concerns of self-neglect. The On 4/8/16 at 2:28 PM CM A spoke with the patient and the friend regarding the home environment. The patient told the CM that Oxygen (O 2) is worn when not smoking. The CM informed the patient that the AAA will be in contact on with her Monday 4/11/16. The patient denied any further CM needs and said discharge will be tomorrow 4/9/16 (Saturday). The record has no further CM notes. The CM notes do identify the patient is on Oxygen at home but do not identify an assessment of home Oxygen needs at discharge or supplier availability.


O 2 orders on admission 4/6/16 at 6:32 PM by Medical Doctor (MD) B state Respiratory Therapy (RT) is to implement the Oximetry Protocol. The order is identified as ongoing. If SpO2 [Oxygen saturation in the blood] is less than 89% oxygen is applied and adjusted to keep the SpO2 greater than or equal to 89%. The order further states that patients who use oxygen at home will be kept at their prescribed oxygen level or greater to keep SpO2 greater than or equal to 89 %. Normal SpO2 levels are 95 -100 % with hypoxia defined as less than 90%. The orders also included aerosol Duo Neb treatments every 6 hours to be given every 6 hours by RT. The aerosol Duo -Neb treatments relax and open the airways to help facilitate breathing.


Record review of RT documentation revealed the patient was requiring continuous O 2 during the entire hospital stay. The patient was on BiPap on 4/6 and 4/7/16 with an O 2 level of 35%. Room air is 21 %. BiPap is a non invasive mechanical pressure support ventilation system that is delivered by mask and reduces the work of breathing by delivering O 2 between 2 different levels of positive airway pressure. Oxygen by mask or nasal cannula was delivered between 2 - 6 liters per minute to maintain SpO2 levels greater than 89% on 4/8 and 4/9/16. On 4/8/16 RT notes at 6:33 PM that the patient was on O 2 at 3 liters/minute and that "this is home O 2 level as well." The SpO2 was 90 % at that time. Review of Vital Sign Flowsheet on 4/9/16 noted that O 2 was at 4 liters per minute by nasal cannula since 3:20 AM. The last vital signs recorded were at 7:03 AM with Oxygen at 4 liters/ minute and SpO2 at 92%. The RT documentation during the stay failed to identify the patient's oxygen needs at discharge or any assessment of how those needs would be met. The record failed to identify any contact with the patient's home oxygen supplier to ensure her needs for Oxygen and related supplies could be met.


Review of discharge instructions 4/9/16 included the aerosol Duo-Neb respiratory treatments every 6 hours as needed for shortness of breath. Neither the medications (Oxygen is a medication) discharge list or written instructions mention the use of Oxygen. The patient signed the instructions indicating they were received and understood. Patient 3 discharged to home at 1:08 PM on Saturday 4/9/16 accompanied by her friend.

B. EMR review of Patient 3's readmission record identified as "3 b" revealed the patient arrived by rescue squad to the ED on Sunday 4/10/16 at 7:00 PM (20 hrs and 52 minutes after discharge). The ED nurses documentation at 7:24 PM notes that Patient 3 just discharged from ICU yesterday for COPD exacerbation [flare up] and was told to wear O 2 at home but "her [oxygen] cord doesn't reach into the living room so she wasn't wearing any when EMS [Emergency Medical Service] arrived, O 2 on their arrival was 77 % on RA [room air]. 77% SpO2 is severely hypoxic (low).


Review of the History and Physical by the attending physician on 4/10/16 at 10:13 PM revealed the patient told the physician that at home normally 2 liters of Oxygen are needed. The patient was continuing to have shortness of breath at rest despite wearing the Oxygen. The patient also stated severe wheezing was present. The patient "called the Oxygen company to increase her Oxygen level but they were not available until Monday (4/11/16)." The patient also admitted "trouble understanding her new medications." Today while in the kitchen the patient tripped and hit her right knee. The neighbor saw this and called 911. On arrival she was wheezing, short of breath and hypoxic at 77%. During the exam the patient was on Oxygen with a saturation level of 90 %. The patient was alert and oriented. The patient was readmitted with diagnosis of acute dyspnea (difficult breathing), acute exacerbation of COPD, Hyponatremia, Single abrasion to right knee and hypoxia. The patient was in the hospital until discharge to an Assisted Living Facility on 4/16/16 (6 days later).

C. Record review of facility policy titled "Discharge Planning" with effective date of 04/90 identifies the policy is to "optimize compliance with the patient's post hospital plan of care." The policy states "High risk criteria for discharge planning is used to help identify patients that have complex needs and/or at risk for readmission requiring a higher level of discharge planning/coordination of care." Patient 3 was identified as being high risk on admission. The policy identifies the "collaboration with other members of the health care team to evaluate the type of after-care needed." The policy also states "All disciplines are asked to assess and document information that will help identify areas of special risk to the patient. Interdisciplinary team meetings are held daily, Monday through Friday to discuss discharge planning needs. An interdisciplinary team evaluates the discharge pan and documentation is completed in the EMR under Case Management." The policy identifies the regular members of the interdisciplinary team include Case Management, Utilization Review, Physical/Occupational Therapist, Dietician, Pharmacy, Respiratory Therapy, the designee from each nursing unit, and any other members as necessary to include all aspects of care. Under the section titled "Anticipated needs/services:" The policy identifies staff are to discuss with the physician the discharge plan and obtain orders if needed. There were no orders for Oxygen at discharge for Patient 3. Staff are to ascertain that the patient has follow-up care at discharge, assess if community resources should be contacted and contact appropriate personnel. Assess the availability of community or other healthcare resources to assist with care including the need for special equipment, supplies or medication.


Record review of facility policy titled "Ordering Home Therapy" effective date 7/92 identifies that Cardiopulmonary Services staff will "assist in the continuum of care for the patient from hospital to home." Upon physician order the RT staff 'will assist with making arrangements for, and in some cases, providing instruction to the patient on proper use of equipment that has been ordered for the patient to use at home." Under the section titled "Procedure" the policy states that "Should it be determined that a patient will require home oxygen, a home equipment evaluation will be performed to assess the needs of the patient."

D. Interview with MD B on 5/26/16 at 1:00 PM revealed the physician was aware the patient was Oxygen dependent at home. MD B stated regarding the discharge on 4/9/16 that "it was my intent to send her home on O 2 therapy." Normally "if a patient is O 2 dependent Respiratory Therapy checks them and assesses their needs before discharge."

E. Staff interview with the Director of Cardiopulmonary Services on 5/25/16 at 3:50 PM confirmed Patient 3's medical record for 4/6-4/9/16 hospital stay did not contain any documentation of RT staff ensuring the patient had an adequate O 2 supply at home or O 2 orders at discharge. The Director confirmed the patient was Oxygen dependent. The Director stated the evaluation for RT needs would have included if the patient has O 2, tubing to reach all areas and a portable source for visiting but that this was not done in this case.