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Based on record review and interviews, the hospital failed to ensure that the physical and medical needs of 1 of 1 patient (Patient #1) were provided. (Patient #1) demonstrated a change in medical condition as evidenced by the following during his 06/05/14 through 06/09/14 hospitalization:

Patient #1 had been admitted to the hospital (Hospital A) in serious condition due to accumulation of fluid in his legs, high blood pressure, critical lab values, and low blood oxygenation. After four days of hospitalization, Patient #1 was discharged home with high blood pressure, fluid in his lungs, and airway restriction unrelieved by medications. Within 13 hours after discharge from Hospital A, Patient #1 sought emergency care at a different hospital (Hospital B) with Stage 2 high blood pressure, shortness of breath requiring six liters of oxygen per minute, nausea, vomiting, and abdominal pain. Patient #1 was emergently dialysis treated and admitted to Hospital B. After six days of hospitalization, Patient #1 left Hospital B in stable condition and with outpatient dialysis treatment in place.

Cross refer to Tag 0144

Based on record review and interviews the hospital failed to provide care in a safe setting for one of one patient (Patient #1) in that Patient #1 had been admitted in serious condition on 06/05/14 with high blood pressure and admitting diagnoses that included Acute Renal/Kidney Failure, Anemia, Weakness, Hyperkalemia, Congestive Heart Failure, and Diabetes with Hyperglycemia. Patient #1's blood pressure during his four day hospitalization was higher than on admission and was not rechecked before he was discharged home on 06/09/14.

Findings included:

Patient #1's Hospital Emergency Department (ED) Physician note dated 06/05/14 at 20:49 reflected Patient #1's past medical history of Hypertension, Diabetes, and Renal Disease. The patient's blood pressure was 190/79 mm Hg (millimeters of Mercury) and had "...3+ edema [swelling]..." in both lower legs. The patient was hospital admitted in "serious" condition. Preliminary diagnoses included Acute Renal/Kidney Failure, Anemia, Weakness, Hyperkalemia, Congestive Heart Failure, and Diabetes with Hyperglycemia.

The History and Physical Exam documentation dated 06/06/14 at 12:26 noted diagnoses included Respiratory Failure with Hypoxemia, Hypertension, and Pulmonary Edema.

Vital Signs Flow Sheets reflected the patient's systolic blood pressure to be greater than 200 mm Hg on 06/06/14 at 19:30 (approximately two and one half hours after dialysis treatment), on 6/07/14 at 12:58 (approximately one half hour after dialysis treatment), on 06/09/14 at 08:18, at 10:43, and at 19:15 (four hours before the patient was discharged).

Physician Progress Notes dated 06/09/14 at 12:17 by Hospital Personnel Physician #12 noted a "most recent" blood pressure of 201/91 mm Hg.

Patient #1's Vital Signs Flow Sheet dated 06/09/14 at 20:30 noted Patient #1's blood pressure was 188/90 mm Hg approximately two and a half hours before he left the hospital.

Nursing Shift Assessment Flow Sheet dated 06/09/14 at 20:55 noted that Hospital Personnel Physician #10 was notified of the patient's blood pressure. The patient was allowed to go home.

Provider Coding Query dated and signed by Hospital A Personnel Physician #10 on 06/10/14 at 08:07 noted Patient #1 had acute pulmonary edema (abnormal build-up of fluid in the air sacs of the lungs which leads to shortness of breath).

On 07/02/14 at 12:05 Hospital Personnel #6 agreed that the last blood pressure before Patient #1's discharge was taken on 06/09/14 at 20:30 and measured 188/90 mm Hg. Hospital A Personnel #6 stated the reading was "considered baseline for this particular patient. His blood pressure was up most of the time."

Hospital Personnel Physician #12 was telephone interviewed on 07/02/14 at approximately 14:30 and acknowledged that Patient #1 had a high blood pressure on discharge but "it fluctuated and did not cause symptoms."

According to the medical records of Hospital A, Patient #1 was discharged home on 06/09/14 with high blood pressure, fluid in his lungs, and airway restriction unrelieved by medications. Within 13 hours after discharge from Hospital A, Patient #1 sought emergency care at a different hospital (Hospital B) with Stage 2 high blood pressure, shortness of breath requiring six liters of oxygen per minute, nausea, vomiting, and abdominal pain. Patient #1 was emergently dialysis treated and admitted to Hospital B.

Based on record review and interview, the hospital failed to have an effective discharge planning process and stabilize an emergent condition for one of one patient (Patient #1) who had been admitted to the hospital in serious condition on 06/05/14 with accumulation of fluid in his legs, high systolic blood pressure in the 190's, and low blood oxygenation. On 06/09/14, Patient #1 was discharged home hypertensive and with restrictive breathing after four days of hospitalization. Thirteen hours later, Patient #1 sought care at a different hospital (Hospital B) and was admitted for emergent dialysis and inpatient hospitalization that same day.

Refer to Tag A 0821

Based on record review and interview, the hospital failed to reassess 1 of 1 Patient's (Patient #1) discharge plan who had been admitted to the hospital in serious condition on 06/05/14 with accumulation of fluid in his legs, high systolic blood pressure in the 190's, and low blood oxygenation. On 06/09/14, Patient #1 was discharged home after personnel noted Patient #1 continued to have Stage 2 hypertension, fluid in his lungs, and airway restrictions unrelieved by medication on the patient's day of discharge (06/09/14). Within 13 hours after Patient #1's discharge, Patient #1 sought care at a different hospital (Hospital B) Emergency Department (ED) with stage 2 hypertension, shortness of breath requiring six liters of oxygen per minute, and respiratory failure. Patient #1 underwent emergent dialysis within five hours, and was admitted to Hospital B.

Findings included:

Patient #1's Emergency Department (ED) Physician note dated 06/05/14 at 20:49 reflected Patient #1's past medical history of Hypertension, Diabetes, and Renal Disease. The patient's blood pressure was 190/79 mm Hg (millimeters of Mercury) and had "...3+ edema [swelling]..." in both lower legs. The patient was hospital admitted in "serious" condition. Preliminary diagnoses included Acute Renal/Kidney Failure, Anemia, Weakness, Hyperkalemia, Congestive Heart Failure, and Diabetes with Hyperglycemia.

History and Physical Exam documentation dated 06/06/14 at 12:26 noted diagnoses included Respiratory Failure with Hypoxemia, Hypertension, and Pulmonary Edema.

Vital Signs Flow Sheets reflected Patient #1's systolic blood pressure to be greater than 200 mm Hg on 06/06/14 at 19:30 (approximately two and one half hours after dialysis treatment), on 6/07/14 at 12:58 (approximately one half hour after dialysis treatment), on 06/09/14 at 08:18, at 10:43, and at 19:15 (four hours before Patient #1 was discharged).

Hemodialysis Records dated 06/09/14 (the day of discharge) at 12:05 noted Patient #1 had "crackles" and "rales" in his lungs.

Physician Progress Notes for Patient #1 dated 06/09/14 at 12:17 by Personnel Physician #12 (Hospital A) noted a "most recent" blood pressure of 201/91 mm Hg.

Hospital Social Work Care Coordination Progress Notes dated 06/09/14 at 17:09 reflected Hospital Personnel Physician #12 was advised that Patient #1 did "...not likely qualify for Medicare and ...can receive compassionate dialysis at ...[Hospital B]."

Vital Signs Flow Sheet dated 06/09/14 at 20:30, noted Patient #1's blood pressure was 188/90 mm Hg approximately two and a half hours before Patient #1 was discharged from Hospital A.

Nursing Shift Assessment Flow Sheet dated 06/09/14 at 20:55 noted that Hospital Personnel Physician #10 was notified of Patient #1's high blood pressure. Patient #1 was allowed to go home.

Pulmonary Function Study dated 06/09/14 noted the spirometry test interpretation that Patient #1's "...airway mechanics reveals moderate airway restriction. Following the inhalation of a bronchodilator, there is no significant improvement in airway mechanics."

Provider Coding Query dated and signed by Personnel Physician #10 on 06/10/14 at 08:07 noted Patient #1 had acute pulmonary edema (abnormal build-up of fluid in the air sacs of the lungs which leads to shortness of breath).Personnel Physician #10's Discharge Summary dated 06/24/14 at 13:05 noted Patient #1's "...blood pressure was also elevated at 190/79...blood pressure control was achieved with oral medications..."

On 07/02/14 at 12:05 Personnel #6 agreed that the last blood pressure before Patient #1's discharge was taken on 06/09/14 at 20:30 and measured 188/90 mm Hg. Hospital A Personnel #6 stated the reading was "considered baseline for this particular patient. His blood pressure was up most of the time."

Personnel Physician #12 was telephone interviewed on 07/02/14 at approximately 14:30 and acknowledged that Patient #1 had a high blood pressure on discharge but "it fluctuated and did not cause symptoms."

Hospital B Admission Information dated 06/10/14 at 12:11 reflected Patient #1's admission diagnoses of Volume Overload and Chronic Kidney Disease. Patient #1 was discharged on 06/16/14 and remained in Hospital B approximately 6 days.

Hospital B's Pulmonary Flow Sheet dated 06/10/14 at 12:52 reflected Patient #1 had "crackles" in his right and left lung.

Hospital B's ED (Emergency Department) Nursing Notes dated 06/10/14 at 13:04 by Personnel #21 (Hospital B) reflected Patient #1 was evaluated for Hypoxia at 12:37. The patient complained of shortness of breath and oxygen was applied via nasal cannula at six liters per minute.

Hospital B's ED Provider Notes dated 06/10/14 at 13:06 by Personnel Physician #19 (Hospital B) noted Patient #1 appeared short of breath. The patient's blood oxygenation saturation was "into the 70's." The patient's blood pressure was 195/95. At 15:46 the physician noted Patient #1's blood pressure was 215/97 mm Hg.

Hospital B's Provider Attending Note dated 06/10/14 at 14:26 by Personnel Physician #20 (Hospital B) noted Patient #1's diagnoses included Hypoxia, Volume Overload, Nausea, and Vomiting. The patient required inpatient hospitalization.

Patient #1's Nephrology Consult dated 06/10/14 at 19:05 by Personnel Physician #25 (Hospital B) reflected Patient #1's severe Shortness of Breath, Orthopnea, and Lower Extremity Swelling. The patient used accessory muscles while breathing, had coarse crackles in his lungs, and was in need of emergency hemodialysis for volume overload. Patient #1 was to receive dialysis treatment three days a week "...while in-house until HD (hemodialysis) center obtained."

Patient #1's History and Physical Exam dated 06/10/14 at 20:07 by Personnel Physician #23(Hospital B) noted Patient #1 had a blood pressure of 207/97 mm Hg. Patient #1 had rales in his lungs, his breathing was fast and shallow on 100 percent oxygen per non-rebreather mask. The chest x-ray showed "florid pulmonary edema." Physician #23's diagnoses included Hypoxia, Respiratory Distress, Pulmonary Edema, End-Stage Renal Disease (ESRD), and Malignant Hypertension. Personnel Physician #23 noted it was "unclear why pt [Patient #1] accumulated fluid so quickly after apparently receiving dialysis...possibly related to uncontrolled HTN [hypertension]." Patient #1 had "emergent dialysis" that night.

The Personnel Physician #27 (Hospital B) Discharge Summary dated 06/16/14 at 15:23 reflected admission diagnoses of Volume Overload, and Chronic Kidney Disease. The patient was hypoxic and hypertensive on admission and required 100 percent oxygen administration per non re-breather mask. The patient received three consecutive sessions of hemodialysis which relieved hypoxia, nausea and vomiting. The patient's high blood pressure improved with dialysis and gradual "up-titrating of anti-HTN (hypertension) medications."

Personnel Physician #24 (Hospital B) was telephone interviewed 07/01/14 at 09:20 and stated Patient #1 came to Hospital B with Pulmonary Edema, Hypoxia, and Uncontrolled Hypertension the morning after discharge from Hospital A and "patients with ESRD [Endstage Renal Disease] do not deteriorate that quickly after dialysis."