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Based on record review and interview the facility failed to implement preventative measures when it was brought to their attention that a patient who required home oxygen was discharged from the facility without oxygen.

This failed practice resulted in the patient becoming oxygen deprived and had to be treated with oxygen and hospitalized at another acute care hospital within two (2) hours of the discharge.
Citing Patient (#1) named in a complaint.
Findings:
During a telephone interview on 6/21/2016 at 10:15 am with Complainant RJ , Social Worker, she stated Patient (# 1) was discharged on the morning of 12/11/2015 from the PP Hospital with orders that she needed home oxygen. The patient arrived at the HH Clinic on 12/11/2015 gasping for breath and could hardly speak. She did not have oxygen with her.

According to RJ, the clinic nurse conducted a six (6) minute walk test with the patient to determine the patients ' oxygen saturation level. After the walk the patient ' s oxygen saturation was 50% on room air.

The patient was evaluated by the Clinic's Physician and oxygen was started via nasal cannula. The patient was transferred to the HH Hospital Emergency Room for evaluation and treatment and was admitted as an inpatient. She spent four ( 4) days in the HH Hospital and was discharged home with oxygen therapy.

Review of Patient #1's clinical record from the HH Clinic dated 12/11/2015 verified that the patient was seen in the clinic at 10:27 am and was sent to the ER at 2:26 pm. She was admitted at the HH Hospital 12/1/2015 at 3:00 pm for 4 days.

During an interview on 6/24/2016 at 9:45 am with Staff G 57, Case Manager she stated she realized the patient should have been discharged to the clinic via ambulance with oxygen. She stated there was a breakdown in communication with the floor Nurse. Usually the staff on the Unit ordered the transportation.

The staff stated on 12/11/2015 a Staff from HH Clinic contacted her with concerns that the patient was sent to the clinic without oxygen. Staff G 57 stated she did not report the occurrence but started to have a discussion with unit staff before patients are discharged.

During an interview on 6/24/2016 at 11:41 am at the facility with Staff A 51, Director of Quality he stated the facility was not aware of this occurrence until the Surveyors came to the facility on 6/23/2016. He stated when Staff G 57 was informed of the problem with the patient's discharge she should have generated an occurrence report so that the facility could have investigated and implemented the correct interventions to ensure this situation never reoccur.

Based on interview and record review the facility failed to evaluate a patient ' s oxygen saturation status prior to discharge when her oxygen therapy was discontinued to ensure she could be safely discharged on room air.

This failed practice resulted in the patient becoming severely oxygen deprived within an hour on room air. Citing Patient (#1) named in a complaint.
Findings:
During a telephone interview on 6/21/2016 at 10:15 am with Complainant RJ , Social Worker, she stated Patient (# 1) was discharged on the morning of 12/11/2015 from the PP Hospital with orders that she needed home oxygen.

The patient arrived at the HH Clinic on 12/11/2015 gasping for breath and could hardly speak. She did not have oxygen with her.

According to RJ, the clinic nurse conducted a six (6) minute walk test with the patient to determine the patients ' oxygen saturation level. After the walk the patient ' s oxygen saturation was 50% on room air.

The patient was evaluated by the Clinic's Physician and oxygen was started via nasal cannula. The patient was transferred to the HH Hospital Emergency Room for evaluation and treatment and was admitted as an inpatient. She spent four ( 4) days in the HH Hospital and was discharged home with oxygen therapy.

Review of Patient #1's clinical record from the HH Clinic dated 12/11/2015 verified that the
patient was seen in the clinic at 10:27 am and was sent to the ER at 2:26 pm. She was
admitted at the HH Hospital 12/1/2015 at 3:00 pm for 4 days.
Review of the patient ' s medical record from Hospital PP revealed the Patient (#1) was
treated in the hospital for seven days for Hypoxia and had been on continuous oxygen therapy.
There was documentation the patient became hypoxic on room air.
Review of Patient # 1's oxygen treatment notes revealed trhe patient was on oxygen via nasal cannula starting on 12/2/2015 date of admission until 12/11/2015 date of discharge. There was
multiple documentation indicating the patient was tried on room air but became hypoxic Not enough oxygen).
Review of nurses notes dated 12/11/2015 revealed at 5;47 am the patient was on 5 liters of oxygen with an oxygen saturation level of 98%.
At 8:51 am the oxygen was decreased to 2 liters via nasal cannula at 100 % saturation.
There was documentation the patient was discharged at 9:30 am in a private car with her daughter.
There was no documentation when the oxygen was discontinued or indication that she was evaluated to determine her oxygen saturation level on room air prior to discharge.
Review of Consultant discharge planning notes dated 12/9/2015 revealed documentation that the patient needed oxygen at home and should not be discharged without oxygen.
During an interview on 6/24/2016 at 10:30 am with Dr.F56,Pulmonary Consultant ,she stated she requested home oxygen for the patient because the patient could not do without the oxygen.

According to Consultant on the day the patient was discharged (12/11/2015) she went to see the patient was informed the patient was discharged home she stated she was very shocked to realize the patient ' s oxygen was "yanked" and she was not evaluated and sent to the clinic in an ambulance with oxygen.

Dr. F 56 stated the patient should have been evaluated after the oxygen was discontinued and should never have left the hospital without oxygen.

Based on interview and record review the facility failed to develop and implement an acceptable discharge plan to ensure that a patient needing continuous oxygen therapy was safely discharged from the hospital with the needed oxygen.

This failed practice resulted in the patient being admitted to an acute care hospital within five(5) hours of discharge due to oxygen depravation. Citing Patient (#1) named in a complaint.
Findings:

During a telephone interview on 6/21/2016 at 10:15 am with Complainant RJ , Social Worker, she stated Patient (# 1) was discharged on the morning of 12/11/2015 from the PP Hospital with orders that she needed home oxygen.

The patient arrived at the HH Clinic on 12/11/2015 gasping for breath and could hardly speak. She did not have oxygen with her.

According to RJ, the clinic nurse conducted a six (6) minute walk test with the patient to determine the patients ' oxygen saturation level. After the walk the patient ' s oxygen saturation was 50% on room air.

The patient was evaluated by the Clinic's Physician and oxygen was started via nasal cannula. The patient was transferred to the HH Hospital Emergency Room for evaluation and
treatment and was admitted as an inpatient. She spent four ( 4) days in the HH Hospital and was discharged home with oxygen therapy.
Review of Patient #1's clinical record from the HH Clinic dated 12/11/2015 verified that the patient was seen in the clinic at 10:27 am and was sent to the ER at 2:26 pm. She was
admitted at the HH Hospital 12/1/2015 at 3:00 pm for 4 days.
Review of the patient ' s medical record from Hospital PP revealed the Patient (#1) was treated in the hospital for seven days for Hypoxia and had been on continuous oxygen therapy.
There was documentation the patient became hypoxic on room air.
Review of Consultant discharge planning notes dated 12/9/2015 revealed documentation that the patient needed oxygen at home and should not be discharged without oxygen.
Review of Case Manager ' s notes dated 12/10/2015 revealed information they were aware the doctor wants the patient to go home with oxygen however the patient's insurance is with the
HH System and the DME Company will only accept orders from a provider of that System.
The discharge plan was to send the patient to HH Clinic where the oxygen would be ordered. There was documentation the patient would be discharged in a private car.
There was no mention of oxygen therapy enroute to the HH clinic.
Review of Nurses notes dated 12/11/2015 (date of discharge) revealed the patient was discharged with her daughter in a private car at 9:30 am.
There was no documentation of the patient's oxygen saturation status upon discharge.
During an interview on 6/24/2016 at 10:30 am with Dr. F56 ,Pulmonary Consultant ,she stated she requested home oxygen for the patient because the patient could not do without the oxygen.

She was aware of the plan to send the patient to HH Clinic on discharge so she could get the oxygen .It was never her intention for staff to send the patient to the clinic in a private car without oxygen, she thought the patient would be safely sent to the clinic via ambulance with oxygen.

During an interview on 6/24/2016 at 9:45 am with Ms. Arnold, Case Manager she stated she realized the patient should have been discharged to the clinic via ambulance with oxygen.
She stated there was a breakdown in communication with the floor Nurse. Usually the staff on the Unit orders the transportation for patients.