HospitalInspections.org

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Based on observation, interview and document review, the hospital failed to to ensure that patients received appropriate discharge planning teaching, failed to provide written discharge instructions to patients and failed to ensure that durable medical equipment was functioning appropriately prior to discharge.

Failure to provide appropriate discharge teaching, written discharge instructions and ensure that durable medical equipment is functioning appropriately can lead to serious adverse medical issues and/or death.

Findings included:

1.The hospital failed to demonstrate that patients receive appropriate discharge teaching related to the operation of durable medical equipment prior to discharge.

Cross Reference Tag A813

2. The hospital failed to provide written discharge instructions to patients

Cross Reference Tag A813

3. The hospital failed to ensure vendors for durable medical equipment provided education and verification of the operation of the equipment.

Cross Reference Tag A813

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Item #1-Discharge Teaching

Based on interview and document review the hospital failed to demonstrate that patients received appropriate discharge teaching related to the operation of durable medical equipment prior to discharge in 2 of 5 patient records reviewed for patients discharging with home oxygen (Patient #1201, Patient #1202, Patient #1203, Patient #1204 and Patient #1205).

Failure to provide appropriate discharge teaching at the time of discharge places patients at risk for serious injury including death.

Findings Included:

1. Document review of the hospital policy titled, "Education/Discharge Instructions: Patient/Caregiver," Policy #6612217 reviewed 07/30/19, showed that the patient/caregiver are to be instructed in a style and manner that is understandable from the patient's perspective regarding safe and effective use of medical equipment.

Review of the hospital's policy titled, "Discharge Planning Policy-Inpatients," Policy #8756423 revised 10/20/20, showed that home oxygen services are to be arranged by the Respiratory Therapy (RT) department and the RN in consultation with the interdisciplinary team should provide patient/family with discharge instructions.

2. On 01/02/21, a 67 year-old patient (Patient #1201) was admitted for treatment of acute respiratory failure and pneumonia due to COVID-19 virus.His comorbidities included Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD) and Insulin Dependent Diabetes Type 2. He was discharged on 01/26/21 to return to the Assisted Living Facility (ALF) where he resided prior to his admission to the hospital. Upon returning to ALF by cab the patient collapsed and became unresponsive. Staff at the ALF stated that the portable O2 equipment that the patient was discharged with was not dispensing oxygen and they attempted to turn it on. It was noted that it was very difficult to turn on. An ambulance was called but the patient was deceased when they arrived.

3. Investigators #9 and #12 conducted medical record review on 02/04/21 with Clinical Informatics Specialists (Staff #1208 and #1209) showed the following:

a. A registered Nurse (RN) documented in the medical record on 01/26/21 at 2:13 PM that an oxygen (O2) tank arrived and the patient was ready for discharge. Home oxygen had been included on the discharge order to run at 1-4 liters per minute via nasal cannula (1-4 L/NC) to keep his oxygen at 92% and/or for any shortness of breath. There was no verification that discharge teaching or education had been provided to Patient #1201 regarding the use of home oxygen equipment.

b. There was no verification that licensed personnel ensured the oxygen equipment was operational prior to Patient #1201 being discharged to an Assisted Living Facility (ALF).

4. On 02/05/21 at 3:30 PM, Investigators #9 and #12 interviewed the Chief Nursing Officer (Staff #1203) regarding discharge instructions and education for patients. Staff #1203 stated that all patients were to receive discharge instructions and education prior to discharge.

5. On 02/04/21 at 10:00 AM, Investigator #9 interviewed the manager of the Respiratory Therapy Department (RT) regarding the process for patients to obtain a home O2 tank prior to discharge. He stated that when the physician orders home oxygen for a patient, RT contacts a community vendor to supply the O2. The vendor then provides education to the patient regarding the use of O2 at home. Document review of the medical record did not detail that a vendor had provided education to the patient.

6. On 12/18/20, a 56 year-old patient (Patient #1202) was admitted for treatment of acute respiratory failure and diagnosed with COVID-19 pneumonia. Hospital staff discharged the patient on 12/26/20. Her comorbidities included severe obesity and low potassium. The review showed the following:

a. A RN documented in the patient's medical record that oxygen was delivered to the patient prior to discharge. Review of the patient's discharge orders showed that the physician ordered the oxygen to run at 1.5 liters per minute via nasal cannula during exercise. There was no verification that discharge teaching or education had been provided to Patient #1202 regarding the use of home oxygen equipment.

b. There was no verification that licensed personnel ensured the oxygen equipment was operational prior to Patient #1202 being discharged to home.

Item #2 Written Discharge Instructions

Based on interview and document review, the hospital failed to provide written discharge instructions to patients regarding use of home oxygen in 2 of 5 patient records reviewed (Patient #1201 and Patient #1202).

Failure to provide appropriate documentation of discharge instructions places patients at risk for serious injury including death.

Findings included:

1. Document review of the hospital's policy titled, "Discharge/Referral/Transfer of Patients," Policy #6512408 reviewed 06/11/19, showed that relevant discharge information and instructions are to be included in the after-visit summary including oxygen needs and home care equipment. The after-visit summary is to include relevant discharge information and instructions including the following: Oxygen needs and home care equipment or supplies needed and the specific equipment and/or the supply vendor is to be provided to the patient with the company name and phone number. The after-visit summary (AVS) report from the Electronic Medical Record (EMR) system is to be printed and a copy of the report given to the patient.

2. Document review of medical records for Patient #1201 dated 01/02/21- 01/26/21 with Clinical Informatics Specialists (Staff #1206, #1208, #1209) showed the following:

a. There was no evidence of documentation of the specific equipment or supply vendor used or that the name and phone number of the home supply company was given to the patient at discharge.

b. There was no verification that a printed "after visit summary" was given to Patient #1201 at the time of discharge.

3. On 02/05/21 at 2:30 PM, Investigator #12 interviewed Clinical Informatics Specialists (Staff #1206) regarding the missing documentation and printed after-visit summary. Staff #1206 verified that there was no evidence of documentation for home care supplies or a name and phone number for the home care company in Patient #1201's medical chart. Staff #1206 verified that an after-visit summary was not printed for patient #1201 on 01/26/21.

4. On 02/05/21 at 2:30 PM, Investigator #12 interviewed the Social Worker Manager (Staff #1210) regarding the after-visit summary. Staff #1210 verified that every patient discharged is to receive a printed copy of the after-visit summary.

5. Document review of medical records for Patient #1202 dated 12/18/20 to 12/26/20 with Clinical Informatics Specialists (Staff #1206, #1208, #1209) showed the following:

a. There was no evidence of documentation of the specific equipment or supply vendor used or that the name and phone number of the home supply company was given to the patient at discharge.

b. Although the patient received an AVS, there were no instructions on the flow rate or when to use home oxygen.

Item #3 Vendor Verification

Based on interview and document review, the hospital failed to ensure vendors for durable medical equipment provided and/or documented education and verification of the operation of the equipment in 2 of 5 patient records reviewed (Patient #1201 and Patient #1202).

Failure to provide appropriate discharge teaching at the time of discharge places patients at risk for serious injury including death.

Findings Included:

1. Document review of the hospitals policy titled, "Discharge Planning-Respiratory Therapy Unit Manual" Policy Stat ID 5912001, last reviewed 01/28/2019, showed that the RT's main responsibility is to arrange home oxygen, home nebulizer, or BiPAP as prescribed by the physician's order and arrange for the equipment to be supplied by a contracted home care company.

2.. Document review of Patient #1201's medical record dated 01/03/21-01/26/21 with Clinical Informatics Specialists (Staff #1206, #1208, #1209) showed the following:

a. A Respiratory Therapist's evaluation summary dated 01/26/21 was completed prior to discharge. The evaluation showed that Patient #1201's oxygen levels were at 85% on room air, 94% on 2 L of O2 at rest and 92% on 2 L when ambulating.

b. There was an order for oxygen in the patient's discharge summary written by the discharging provider.

c. The nursing discharge summary dated 01/26/21 showed that an oxygen tank was delivered to the patient prior to discharge.

d. There was no evidence that Patient #1201 received education or training on the use of his oxygen equipment prior to discharge.

3. Document review of Patient #1202's medical record dated 12/18/20 to 12/26/20 with Clinical Informatics Specialists (Staff #1206, #1208 and #1209) showed the following:

a. A Respiratory Therapist's evaluation summary dated 12/26/20 was completed prior to discharge. The evaluation showed that Patient #1202's oxygen levels were at 92% on room air resting, 87% on room air exercising and 91% on 1.5 L of oxygen when exercising.

b. There was an order for oxygen in the patient's discharge summary written by the discharging provider.

c. The nursing discharge summary dated 12/26/20 showed that an oxygen tank was delivered to the patient prior to discharge.

d. There was no evidence that Patient #1202 received education or training on the use of her oxygen equipment prior to discharge.

4. On 02/04/21 at 1:30 PM, Investigator #12 interviewed a Respiratory Therapist (RT) (Staff #1211) regarding home oxygen equipment. Staff #1211 stated that the RT acknowledges the physician's orders and does a respiratory assessment of the patient prior to discharge. Staff #1211 stated that if the patient meets the criteria the "home care company" is notified. Staff #1211 stated that the "home care company" brings the tank and does the patient education.

5. On 02/05/21 at 3:45 PM, Investigator #12 interviewed the Executive Director of Quality, Safety and Risk Management (Staff #1201) and Clinical Informatics Specialist (Staff #1206) regarding verification that Patients #1201 and #1202 had received education and training on the use of the delivered oxygen equipment. Staff #1201 and Staff #1206 verified that there was no evidence that Patient #1201 received the education or training on the use of oxygen equipment.