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Based on review of documentation and interview, it was determined that facility nursing staff failed ensure the safety of its patients at time of discharge.

Findings were:

Patient # 1 was discharged from Central Texas Medical Center on 1/20/15. At 11:22 am that day, he recieved 3 units of fast acting insulin and 5 units of "basil" (routine) insulin for a blood glucose reading of 226. There is no documented record of Patient # 1's intake that day--including breakfast and lunch. Patient # 1 was discharged to a skilled nursing facility at 4pm that afternoon and was found unresponsive after arrival. His blood glucose was measured at 21.

In an interview with the RN Risk Manager on 4/29/15, the above senerio was confirmed. She acknowledged that there was no documented evidence of Patient #1's food or liquid intake that day.

Based on a review of documentation and interview, it was determined that the facility failed to notify family members of Patient # 1 of his pending discharge.

Findings were:

On 1/20/15, Patient # 1 was discharged from Central Texas Medical Center. Family members requested notification of discharge from patient's primary nurse. The patient was discharged without family notification.

In an interview with the primary nurse of Patient # 1 on 4/29/15, the failed communication was confirmed.