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Based on medical record review and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care at the time of discharge for one (1) of one (1) closed patient records reviewed (patient #1). This failure creates the potential for the care and condition of patients who are discharged to be adversely impacted.

Findings include:

1. The State Agency received a complaint alleging patient #1, who uses continuous oxygen at home, was discharged from the hospital without oxygen and left outside when no one was there to pick him up.

2. Review of 10/08/11 physician orders for patient #1 revealed nasal oxygen was ordered at two (2) - four (4) liters per minute. Review of all physician's orders revealed no order to discontinue use of oxygen.

3. Review of the 10/10/11 Discharge Instructions provided to the patient revealed no mention of oxygen. These Instructions were signed by the Nurse at 1520.

4. Review of the medical record revealed no nursing note to reflect the patient's condition at discharge, manner of discharge or time of discharge. The time of the last nursing assessment of the patient on the date of discharge was 0730.

5. Interview was conducted in the late morning of 10/31/11 with Registered Nurse #1 who signed the Discharge Instructions. She confirmed she had not made a discharge note. She was uncertain as to the time the patient left the hospital but estimated the time as approximately 1630 on 10/10/11.

6. The Nurse confirmed the Instructions did not mention the use of oxygen. She stated she reviewed the Discharge Instructions with the patient. She stated she did not remember if the patient was using oxygen at the time the instructions were reviewed. She confirmed she did not discuss the use of oxygen or any arrangements for use of home oxygen with the patient. She stated the patient had originally planned to go home by ambulance and after review of the discharge instructions he told her he needed to arrange for someone to come get him.

7. The Nurse stated she told the patient/family she would be back to take the patient out of the hospital when she finished doing something for another patient. The Nurse confirmed that hospital expectation is that patients are accompanied to the door by hospital staff. She stated when she returned to the patient's room the patient was gone. The discharge nurse confirmed she did not look for the patient. She confirmed she did not document a discharge note or report the patient left the hospital without being accompanied by staff.

Based on medical record review, document review and staff interview it was determined the hospital failed to ensure the need for discharge planning was addressed in the Initial Admission Assessment per policy for one (1) of one (1) closed patient records reviewed (patient #1). This failure creates the potential for the needs of all patients who require discharge planning to be missed.

Findings include:

1. The policy "High Risk Screening & Scope of Psychosocial Assessments of Patients," Revised 4/09, was provided for review. The policy states in part: "The need for discharge planning or Social Work intervention is an on-going and daily part of the nursing assessment and patient care plan...The initial assessment of discharge planning needs occurs through the Nursing staff screening questions on the 'Interdisciplinary Assessment.'

2. The policy "Assessment of Patient," revised 8/10, was provided for review. The policy states in part: "Specific components of the initial assessment have been identified to be used as triggers to warrant further nutritional/hydration, social, and functional assessments by the respective disciplines...The need for discharge planning is addressed during the initial assessment."

3. Review of the 10/8/11 Initial Assessment for patient #1 revealed the nurse documented the 72 year old patient had multiple chronic medical conditions. She noted the patient was dependent upon assistance in self-care. Immobility, weakness, visual deficit, numbness and difficulty swallowing were also noted. She also noted the patient was using O2 continuously with a BiPAP (bilevel positive airway pressure) machine used at night. The assessment failed to identify what medical equipment was available in the home. The patient's functional total score was recorded by the nurse as twelve (12 ) with a note that if score is between eleveen (11) and twelve (12), the patient is appropriate for further assessment by Occupational Therapy and Physical Therapy.

This assessment failed to trigger a referral or consult with Case Management or Social Work related to discharge planning needs. Review of the record revealed the patient received no followup related to discharge planning needs.

4. During the early afternoon of 10/31/11 a joint interview was conducted with the 4th Floor Team 2 Social Worker and the Director of Case Management. During this interview this record was reviewed and discussed. Both acknowleged that neither Case Management or Social Work was consulted to assess post hospital equipment needs. The Director of Case Management acknowleged that all screening questions had not been answered and indicated the Case Management/Social Work Screening policy/process needed revised.

Based on medical record review and staff interview it was determined the hospital failed to ensure arrangements were made for home oxygen for one (1) of one (1) closed patient records reviewed (patient #1). This failure has the potential to adversely impact the post hospital needs of all patients.

Findings include:

1. The State Agency received a complaint alleging patient #1, who uses continuous oxygen at home, was discharged from the hospital without oxygen and left outside when no one was there to pick him up.

2. Review of 10/08/11 physician orders for patient #1 revealed nasal oxygen was ordered at two (2) - four (4) liters per minute. Review of all physician's orders revealed no order to discontinue use of oxygen.

3. Review of the 10/10/11 Discharge Instructions provided to the patient revealed no mention of oxygen.

4. Interview was conducted in the late morning of 10/31/11 with Registered Nurse #1 who signed the Discharge Instructions. The Nurse confirmed the Instructions did not mention the use of oxygen. She stated she reviewed the Discharge Instructions with the patient. She stated she did not remember if the patient was using oxygen at the time the instructions were reviewed. She confirmed she did not discuss the use of oxygen or arrangements for home oxygen with the patient.

5. Review of the medical record for patient #1 revealed no Case Management or Social Work consult was made.

6. During the early afternoon of 10/31/11 a joint interview was conducted with the 4th Floor Team 2 Social Worker and the Director of Case Management. During this interview this record was reviewed and discussed. Both acknowleged that neither Case Management or Social Work was consulted to assess post hospital equipment needs.