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Based on interview and document review, the hospital failed to arrange for essential medical equipment (oxygen) prior to the patient's discharge for 1 of 5 patients (P7) reviewed for discharge planning.

Findings include:

On 5/15/25 at 1:06 p.m. P7's durable medical equipment progress note indicated P7 would benefit from home oxygen therapy following home oxygen assessment.

On 5/15/25 at 3:04 p.m. P7's social work progress note indicated P7's family had chosen and been accepted by a hospice agency.

On 5/16/25 at 12:12 p.m. P7's provider discharge orders included oxygen for home use with bubbler/humidity as needed for patient comfort. Liters per minute: 4 per nasal cannula.

On 5/16/25 at 11:37 a.m. P7's social work progress note indicated social worker (SW)-A had spoken with P7's daughter, a registered nurse (RN) at the assisted living facility (ALF) P7 would be returning to, and a hospice RN. All parties were agreeable to the discharge plan. The ALF requested P7 be discharged with oxygen.

On 5/22/25 at 9:28 a.m., hospice registered nurse (RN)-C stated P7 had been accepted by the hospice agency. A SW from the hospital called the hospice company on Friday to inform them of the transport time, but did not mention the need for supplemental oxygen. When R7 arrived home, she was utilizing 6 liters of oxygen which was provided by the medical transport. There was no supplemental oxygen at P7's home, so the medical transport team waited while the hospice agency sent at an immediate delivery order to the oxygen supply company. The medical transport team waited about 2 hours for the oxygen to be delivered. The hospice agency did not receive P7's discharge orders until Monday (3 days after discharge).

On 5/22/25 at 12:29 p.m., RN-A stated the hospital nurse discharging a patient needed to call the oxygen supply company to set up a delivery time, and confirm with the family there would be someone at the home to receive the delivery. Nurses do not call to ensure the oxygen was delivered.

On 5/23/25 at 9:22 a.m., RN-B stated when a patient who required oxygen is being discharged, the discharging nurse will call the oxygen delivery company to set up a delivery time before the patient discharges. It is important the oxygen is delivered before the patient discharges so the patient can use it as soon as they are home. If a patient started hospice before they discharged from the hospital, it was the hospice agency's duty to be sure the oxygen was delivered. RN-B could not recall P7's discharge, but stated she entered all the discharge information she was provided in the nursing discharge note.

On 5/23/2025 at 9:30 a.m., social worker (SW)-A stated the bedside nurse coordinated with the oxygen supply company. A social worker would arrange a transport time based on the time of the oxygen delivery. It was important the equipment was delivered before the patient arrived home. SW-A could not recall specifics of P7's discharge.

On 5/23/2025 at 10:11 a.m., SW-B was interviewed and stated it is the hospice agency's responsibility to coordinate delivery with oxygen supply company. The hospital social worker should set up a transportation time based on the oxygen delivery time provided by the hospice company.

On 5/23/2025 at 11:34 a.m., the RN care coordinator (RN)-D stated the hospice agency would order any durable medical equipment including oxygen. The RNCC would not be involved with oxygen delivery.

The facility Standard Work Activity Sheet Hospice Post-Acute dated 10/22/24 instructed the social worker to ensure hospice has arranged durable medical equipment, if needed, and confirm medications to be filled at hospital or elsewhere.

The Discharge Planning/Discharge Patients policy dated April 2024 directed the staff RN to facility timely discharge via coordination with members of the care team including coordinating acquisition of resources/equipment/supplies, so items are available for patient upon leaving the hospital.