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Based on record review, and interviews, the hospital did not ensure that they had reassessed the patient's discharge plan for 1 of 10 patients (Patients #1), when there were identified respiratory care factors that could effect continuing home care needs, and the appropriateness of the discharge plan.

Findings Included:

Review of the medical record for Patient #1 revealed she was admitted 9/11/13 for a gastric sleeve procedure and hernia repair. Her pre-operative diagnoses were: Morbid obesity, Heartburn, and Hiatal Hernia. Oxygen saturation 95%.

Patient #1's hospital course noted the following documentation:

9/11/13: Day of Admission:
-2:09 PM: Patient #1's admission to the Medical/Surgical (M/S) unit, the Licensed Vocational Nurse (LVN) (Personnel #12) noted "The range for O2 Saturation (%), Normal: 88-100...Oxygen Flow at 4.5 L (liters) - Patient de-sating (decrease in oxygen saturation) while asleep to low 80's even with O2 (oxygen)...via nasal cannula."
-7:54 PM: The Registered Nurse (RN) (Personnel #13), noted "mask, oxygen flow at 4-5 liters, d/t (due to) patient desaturations while asleep."

9/12/13: Day of Discharge:
-7:05 AM: The LVN (Personnel #9), noted "...oxygen flow: mask at 4-5 liters due to sats (oxygen saturation) dropping while asleep."
-8:05 AM: The RN (Personnel #17), noted oxygen saturation to be 98%.
-9:20 AM: The Respiratory Therapist (RT) (Personnel #11), noted "Oxygen Protocol, currently on Room Air with an oxygen saturation of 81%...increased (placed patient on) oxygen to 4 lpm (liters per minute), NC (nasal cannula)."
-9:50 AM: The Nurse Practitioner (NP) (Personnel #8), noted Patient #1 "doing well, no complaints, pain controlled," and repeated the documented 8:05 AM nurse's vital signs including "oxygen saturation of 98%...suspected OSA (obstructive sleep apnea) - stable, should improve with weight loss...DC (discharge) today if 2nd UGI (upper gastro-intestinal exam) is also negative..."
-1:00 PM: The NP's (Personnel #8), "Discharge Order Set," noted "Discharge patient to home...follow-up with Physician #7 (bariatric surgeon) in one (1) week...Patient to see Physician #18 ASAP (as soon as possible), follow-up...for sleep study."
-4:00 PM: The RT (Personnel #11), noted "oxygen saturation at this time is 57%...patient sleeping, possible sleep apnea, patient had blue tinge to her skin and was lethargic upon entering the room, placed patient on simple mask and woke patient as much as possible and instructed to breathe deep...patient responded well, saturation climbed to 95 (%) on a simple mask with a little effort...resting saturations fluctuate between 88 - 95 (%) due to apneic episodes while sleeping...recommended patient be placed on cpap (continuous positive airway pressure) at night, waiting on doctors decision."
-5:36 PM: Discharge Assessment by the LVN (Personnel #9), included vital signs "respiratory rate 20, with lung sounds clear to auscultation," but did not include Patient #1's oxygen saturation in the medical record, or that it was re-checked prior to her discharge.

There was no documentation in Patient #1's medical record on day of discharge by the LVN (Personnel #9), regarding a reassessment of the 57% oxygen saturation, and/or other respiratory factors that could affect continuing home care needs.

Interviews:

In an interview at 1:00 PM on 11/13/13 with the Assistant Director of M/S Nursing (Personnel #6), she said "the Bariatric patients usually come in for surgery one day, spend the night, and go home the next day...and that they do not usually require any discharge planning...the patient's nurse would notify Case Management if there were any identified patient discharge needs." Personnel #6 verified there was no request in the medical record for identified needs, to Case Management for discharge planning services for Patient #1, that included respiratory needs.

The hospital's "Discharge Planning" policy, last revised August 2008, noted "discharge planning will be instituted upon patient admission...this plan will be evaluated and revised as care needs change to facilitate the highest quality individualized patient care...referrals will be made to all appropriate entities, providing access to higher levels of care and professional consultation...all involved disciplines are responsible for discharge planning and communication, and documentation of such to the patient, family, and other caregivers."