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Based on interviews and document reviews the facility failed to integrate support services and assess discharge readiness to ensure a safe transition of care from the emergency room in 3 out of 20 patients (Patients #1, #5 and #13).

This failure created the potential for patients with ongoing medical conditions to be discharged to inappropriate environments without the ability to manage medical conditions due to lack of services, equipment, and resources.

POLICY

According to Guidelines for Nursing Care of the Emergency Department (ED) Patient, the plan of care will be individualized and based on patient needs or condition, the plan will be developed through collaboration among members of the health care team and the patient, documentation will reflect the standard of care specific to the patient's presenting problem. Documentation will include ongoing assessment, reassessment and evaluation. Care/focused assessment and vital signs of the patient will be documented a minimum of every 2 hours based on patient's clinical condition. Vital signs will be reassessed within thirty (30) minutes prior to discharge, excluding non-urgent patients with normal vital signs at presentation. All finding from nursing assessment and reassessment will be documented. In addition to ED nursing care, ancillary services such a social service, chaplain, psychiatric services, and home health care will be provided when indicated. At patient's discharge assure the patient is capable of self-care or has access to support services. Arrangement for home health care may be initiated by the ED Case Manager or the patient's primary nurse. The patient will be assessed for readiness to will which will include cognitive understanding. Documentation will indicate patient condition and aftercare instructions provided to the patient and/or family prior to discharge.

1. The facility failed to provide post-discharge resources to Patient #1 to ensure a safe discharge and transition from the Emergency Room to home/self-care.

a) A review of Patient #1's medical record revealed s/he presented to the Emergency Department (ED), on 06/27/16, on 3 liters (L) oxygen (O2) via nasal cannula (NC) upon arrival by ambulance. It was noted in Patient #1's medical record s/he suffered from chronic obstructive pulmonary disease (COPD) and lived in a skilled nursing facility.

At 06/28/16 at 1:57 p.m. the medical record revealed Case Manager #1 had reported the nursing home did not want the patient to return there to live. The family was to be notified and they could arrange for placement. Case Manager #1 documentation on 06/28/16 at 4:57 p.m., revealed disposition to an acute living facility was discussed with the brother and a senior blue book was provided as a community resource.

However, the patient was discharged home in the care of his/her brother. No additional post-discharge resources were noted as provided or discussed with the patient to ensure a safe transition home.

There was no documentation the patient was set up with home oxygen services prior to discharge. Patient #1 was discharged at 6:30 p.m. on 06/28/16.

b) During an interview on 09/21/16 at 9:18 a.m., Case Manager #4 stated part of his/her job included assisting patients with transfers to hospice, home health set up, resources regarding addictions and follow-up services. S/he would also assist with transfers to Skilled Nursing Facilities. The case managers worked with families and provided a list of facilities. Patients would stay in the ED until placement was made and until the facility could ensure the environment the patients were going to was safe for them. S/he assumed a patient would stay in the ED if a discharge home was not safe for them. S/he further stated the facility needed to ensure a safe plan for the patient.

c) During an interview with Case Manager #1 on 09/22/16 at 11:20 a.m., s/he stated the case manager position was a lot of self-discovery, it was his/her responsibility to decide if an emergency room patient needed case management services. Case Manager #1 did not have a checklist or flowsheet to determine patient needs to get home from the ED safely. Case Manager #1 admitted patients in need of his/her services in the emergency room could "most definitely" be missed with the current process.

During the same interview on 09/22/16 at 11:20 a.m. Case Manager #1 reviewed the medical record of Patient #1. S/he stated Patient #1's medical needs were not discussed with the long term facility from which Patient #1 was brought. Case Manager #1 was unaware and did not question if the patient needed medical equipment or services for a safe discharge home with family. Case Manager #1 stated medical equipment was typically something families and patients needed to figure out on their own. S/he further stated s/he did not have a discharge plan in place for Patient #1.

d) During an interview on 09/22/16 at 1:32 p.m., The Director of Case Management (Director #2) stated s/he expected the ED case managers to assess the patient's physical and medical needs. The case manager needed to determine if a patient needed home health at time of discharge. Director #2 expected to see this documented in the medical record. Upon review of Patient #1's medical record during the interview, Director #2 stated s/he expected to see documentation of the other facility being notified and medical equipment and supplies reviewed. S/he further stated more information was needed in the medical record to determine if Patient #1's discharge to home was safe.

2. The facility failed to assess patient's vital signs and O2 saturation levels within 30 minutes prior to discharge pursuant to the policy.

a) A review of Patient #1's medical record revealed s/he presented to the ED on 3L O2 via NC upon arrival by ambulance. It was noted in Patient #1's medical record s/he suffered from COPD and lived in a skilled nursing facility.

Respiratory assessments per the emergency department revealed Patient #1 had an oxygen saturation of 97% with administered O2 on 06/27/16 at 10:31 p.m. during his/her initial ER assessment. Further documentation review revealed the patient remained on O2 with documentation of O2 saturation levels through 06/28/16 at 8:48 a.m. On 06/28/16 at 12:19 p.m. documentation revealed Patient #1's oxygen saturation was 94%, it was not documented if the patient was on room air or remained on O2. No further vital signs for oxygen saturations were recorded for the patient and a room air oxygen saturation was not recorded. There was no documentation respiratory therapy was notified regarding a COPD patient on O2. Patient #1 was discharged to home from the ED at 6:30 p.m. on 06/28/16.

b) A review of Patient #5's medical record revealed s/he was discharged at 4:22 p.m. on 07/14/16. The last set of vital signs assessed for patient #5 was at 3:10 p.m. on 07/14/16. This was not in accordance with facility policy regarding the timeframe of patient assessment prior to discharge.

A review of Patient #13's medical record revealed his/her vital signs were taken at 5:49 p.m. on 09/07/16. The next set of vital signs were recorded at 10:05 p.m. This was outside the facility policy timeframe of 2 hours to assess the vital signs of an emergency room patient.

c) During an interview on 09/22/16 at 12:19 p.m., RN #5 stated if a patient was on oxygen a room air saturation must be charted as well. A room air saturation was not documented on Patient #1's chart. S/he stated vital signs and assessments of an emergency department patient should follow the policy. RN #5 further stated it was the case manager's responsibility to ensure the patient's discharge was safe. S/he stated patients were able to stay overnight in the emergency department if a safe place to discharge was not determined.

d) During an interview with Vice President of Emergency Services (VP) # 3 on 09/22/16 at 2:16 p.m., s/he stated s/he would expect to see a set of vital signs and a physical assessment of patients at discharge. S/he was unsure if a room air challenge was needed on patient's receiving oxygen while in the Emergency Department. VP #3 stated the Department relied on family to know the needs of the patient. S/he further stated that the facility did not get involved with medical equipment for a patient if it was after business hours.

Based on interviews and document reviews the facility failed to integrate support services and assess discharge readiness to ensure a safe transition of care from the emergency room in 3 out of 20 patients (Patients #1, #5 and #13).

This failure created the potential for patients with ongoing medical conditions to be discharged to inappropriate environments without the ability to manage medical conditions due to lack of services, equipment, and resources.

POLICY

According to Guidelines for Nursing Care of the Emergency Department (ED) Patient, the plan of care will be individualized and based on patient needs or condition, the plan will be developed through collaboration among members of the health care team and the patient, documentation will reflect the standard of care specific to the patient's presenting problem. Documentation will include ongoing assessment, reassessment and evaluation. Care/focused assessment and vital signs of the patient will be documented a minimum of every 2 hours based on patient's clinical condition. Vital signs will be reassessed within thirty (30) minutes prior to discharge, excluding non-urgent patients with normal vital signs at presentation. All finding from nursing assessment and reassessment will be documented. In addition to ED nursing care, ancillary services such a social service, chaplain, psychiatric services, and home health care will be provided when indicated. At patient's discharge assure the patient is capable of self-care or has access to support services. Arrangement for home health care may be initiated by the ED Case Manager or the patient's primary nurse. The patient will be assessed for readiness to will which will include cognitive understanding. Documentation will indicate patient condition and aftercare instructions provided to the patient and/or family prior to discharge.

1. The facility failed to provide post-discharge resources to Patient #1 to ensure a safe discharge and transition from the Emergency Room to home/self-care.

a) A review of Patient #1's medical record revealed s/he presented to the Emergency Department (ED), on 06/27/16, on 3 liters (L) oxygen (O2) via nasal cannula (NC) upon arrival by ambulance. It was noted in Patient #1's medical record s/he suffered from chronic obstructive pulmonary disease (COPD) and lived in a skilled nursing facility.

At 06/28/16 at 1:57 p.m. the medical record revealed Case Manager #1 had reported the nursing home did not want the patient to return there to live. The family was to be notified and they could arrange for placement. Case Manager #1 documentation on 06/28/16 at 4:57 p.m., revealed disposition to an acute living facility was discussed with the brother and a senior blue book was provided as a community resource.

However, the patient was discharged home in the care of his/her brother. No additional post-discharge resources were noted as provided or discussed with the patient to ensure a safe transition home.

There was no documentation the patient was set up with home oxygen services prior to discharge. Patient #1 was discharged at 6:30 p.m. on 06/28/16.

b) During an interview on 09/21/16 at 9:18 a.m., Case Manager #4 stated part of his/her job included assisting patients with transfers to hospice, home health set up, resources regarding addictions and follow-up services. S/he would also assist with transfers to Skilled Nursing Facilities. The case managers worked with families and provided a list of facilities. Patients would stay in the ED until placement was made and until the facility could ensure the environment the patients were going to was safe for them. S/he assumed a patient would stay in the ED if a discharge home was not safe for them. S/he further stated the facility needed to ensure a safe plan for the patient.

c) During an interview with Case Manager #1 on 09/22/16 at 11:20 a.m., s/he stated the case manager position was a lot of self-discovery, it was his/her responsibility to decide if an emergency room patient needed case management services. Case Manager #1 did not have a checklist or flowsheet to determine patient needs to get home from the ED safely. Case Manager #1 admitted patients in need of his/her services in the emergency room could "most definitely" be missed with the current process.

During the same interview on 09/22/16 at 11:20 a.m. Case Manager #1 reviewed the medical record of Patient #1. S/he stated Patient #1's medical needs were not discussed with the long term facility from which Patient #1 was brought. Case Manager #1 was unaware and did not question if the patient needed medical equipment or services for a safe discharge home with family. Case Manager #1 stated medical equipment was typically something families and patients needed to figure out on their own. S/he further stated s/he did not have a discharge plan in place for Patient #1.

d) During an interview on 09/22/16 at 1:32 p.m., The Director of Case Management (Director #2) stated s/he expected the ED case managers to assess the patient's physical and medical needs. The case manager needed to determine if a patient needed home health at time of discharge. Director #2 expected to see this documented in the medical record. Upon review of Patient #1's medical record during the interview, Director #2 stated s/he expected to see documentation of the other facility being notified and medical equipment and supplies reviewed. S/he further stated more information was needed in the medical record to determine if Patient #1's discharge to home was safe.

2. The facility failed to assess patient's vital signs and O2 saturation levels within 30 minutes prior to discharge pursuant to the policy.

a) A review of Patient #1's medical record revealed s/he presented to the ED on 3L O2 via NC upon arrival by ambulance. It was noted in Patient #1's medical record s/he suffered from COPD and lived in a skilled nursing facility.

Respiratory assessments per the emergency department revealed Patient #1 had an oxygen saturation of 97% with administered O2 on 06/27/16 at 10:31 p.m. during his/her initial ER assessment. Further documentation review revealed the patient remained on O2 with documentation of O2 saturation levels through 06/28/16 at 8:48 a.m. On 06/28/16 at 12:19 p.m. documentation revealed Patient #1's oxygen saturation was 94%, it was not documented if the patient was on room air or remained on O2. No further vital signs for oxygen saturations were recorded for the patient and a room air oxygen saturation was not recorded. There was no documentation respiratory therapy was notified regarding a COPD patient on O2. Patient #1 was discharged to home from the ED at 6:30 p.m. on 06/28/16.

b) A review of Patient #5's medical record revealed s/he was discharged at 4:22 p.m. on 07/14/16. The last set of vital signs assessed for patient #5 was at 3:10 p.m. on 07/14/16. This was not in accordance with facility policy regarding the timeframe of patient assessment prior to discharge.

A review of Patient #13's medical record revealed his/her vital signs were taken at 5:49 p.m. on 09/07/16. The next set of vital signs were recorded at 10:05 p.m. This was outside the facility policy timeframe of 2 hours to assess the vital signs of an emergency room patient.

c) During an interview on 09/22/16 at 12:19 p.m., RN #5 stated if a patient was on oxygen a room air saturation must be charted as well. A room air saturation was not documented on Patient #1's chart. S/he stated vital signs and assessments of an emergency department patient should follow the policy. RN #5 further stated it was the case manager's responsibility to ensure the patient's discharge was safe. S/he stated patients were able to stay overnight in the emergency department if a safe place to discharge was not determined.

d) During an interview with Vice President of Emergency Services (VP) # 3 on 09/22/16 at 2:16 p.m., s/he stated s/he would expect to see a set of vital signs and a physical assessment of patients at discharge. S/he was unsure if a room air challenge was needed on patient's receiving oxygen while in the Emergency Department. VP #3 stated the Department relied on family to know the needs of the patient. S/he further stated that the facility did not get involved with medical equipment for a patient if it was after business hours.