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Based on interview and document review, the facility failed to update the provider and get an order for oxygen for 1 of 10 patients (P3). P3 was started on oxygen without his provider's knowledge, discharged without the needed supplemental oxygen supplies, and subsequently required an immediate transfer to a local hospital to receive supplemental oxygen.

As a result, the hospital was found out of compliance with the Condition of Participation Nursing Services at 42 CFR 482.45.

A condition level deficiency was issued at A0385. See A0395 for additional information.

Based on interview and document review, the facility failed to update the provider and get an order for oxygen for 1 of 10 patients (P3). P3 was started on oxygen without his provider's knowledge, discharged without the needed supplemental oxygen supplies, and subsequently required an immediate transfer to a local hospital to receive supplemental oxygen.

Findings include:

P3's Face Sheet indicated P3 admitted on 4/25/25 and discharged on 5/1/25.

P3's Diagnoses List dated 4/25/25 included non-ST elevated myocardial infarction, anemia, and history of transient ischemic attack.

On 4/30/25 at 6:39 p.m. a nursing note written by registered nurse (RN)-D indicated P3's oxygen saturations had dropped to 85% with increased work of breathing. 4L of supplemental oxygen was provided via nasal cannula. The note lacked documentation of notifying P3's provider.

On 5/1/25 at 1:04 p.m. a provider discharge summary lacked information about P3's use of supplemental oxygen.

On 5/1/25 at 2:01 p.m. a discharge note lacked information about P3's use of supplemental oxygen.

On 5/1/25 at 6:18 p.m. a nursing note written by RN-E indicated P3 was utilizing 2L of supplemental oxygen.

P3's EMR lacked documentation of a supplemental oxygen provider order.

P3's Emergency Medical Services (EMS) Transportation run sheet dated 5/1/25 indicated P3 was picked up from the hospital at 1:46 p.m. P3 utilized 2L of supplemental oxygen during the transportation to the assisted living facility (ALF). P3 arrived at the ALF at 2:58 p.m. EMS transport team departed the ALF at 3:45 p.m.

P3's EMS Patient Care Report dated 5/1/25 indicated P3 was picked up from the ALF at 3:54 p.m. and transported to the local hospital. The report also indicated P3 was placed on 3L of supplemental oxygen for low oxygen saturations during transportation to the local hospital.

On 6/3/25 at 2:13 p.m., a representative from P3's ALF (R)-A stated P3 arrived at the ALF utilizing supplemental oxygen. P3 did not have any personal oxygen equipment at the assisted living. P3 would need a provider order to obtain supplemental oxygen equipment, but there was no provider order for oxygen in P3's discharge orders.

On 6/4/25 at 1:50 p.m., a registered nurse from P3's ALF (RN)-F was interviewed and stated she was the nurse responsible for taking nurse to nurse reports. She was not informed of P3's utilization of supplemental oxygen. She was present when P3 returned to the ALF utilizing supplemental oxygen. When the supplemental oxygen was removed, P3's oxygen saturation would drop. She called 911 immediately to transport P3 to the nearest (local) hospital because the ALF did not have the needed oxygen supply equipment. P3 was admitted to the local hospital for four days with a primary diagnosis of weakness.

On 6/3/2025 at 2:28 p.m., registered nurse (RN)-A stated she was the registered nurse care coordinator (RNCC) who had reviewed P3's discharge orders on the day of discharge. She had not noticed P3 had been placed on supplemental oxygen overnight. The bedside nurse did not complete the Oxygen Saturations Note, or place a RNCC consult. P3 did not have a provider order for supplemental oxygen. RN-A stated it was the RNCC's responsibility to check for a provider order for home oxygen, and arrange for transport supplemental oxygen if the patient was going to a facility. The receiving facility would be responsible for setting up delivery of supplemental oxygen equipment at their facility.

On 6/4/25 at 3:00 p.m., medical doctor (MD)-A stated she was P3's discharging provider. She had not been notified P3 had been placed on supplemental oxygen. If she had been aware, she would have placed the appropriate orders for home oxygen.

On 6/5/25 at 12:32 p.m., RN-E stated she would not have looked for an order for oxygen, or updated the provider, because P3 was utilizing supplemental oxygen when she assumed his care. When a patient needed supplemental oxygen, the nurse starting the oxygen should write a nursing note. If the patient required more than 2L, the provider should be notified right away. If 2L was adequate, the provider did not need to be updated, because the providers read the nursing notes.

On 6/5/25 at 12:44 p.m., a message was left for RN-D with no return phone call.

On 6/5/2025 at 1:01 p.m., RN-C stated providers were notified of patient changes via secure message or a page. The communication should be documented in a provider notification note. P3's EMR did not contain an Oxygen Saturations note that was required when a patient would be discharging with home oxygen. The nurse completing the oxygen saturations note should also contact the RNCC to arrange supplementary oxygen equipment for after discharge. P3 did not have an order for home oxygen, and the documentation in P3's chart made it sound like he was not on supplemental oxygen when he left the facility.

The facility Oxygen Assessment and Management policy dated 3/25 directed to notify the covering provider after initiating supplemental oxygen.

A policy on patient change in condition and notification of provider was requested, but not provided.