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Based on policy review, medical record review and interview, nursing staff did not assess Patient #1 and/or notify the physician prior to discharge, despite a change in his condition.

Findings include:

Review of policy "Guidelines for the Discharge of the Patient and Discharge Plan" effective 05/30/17 indicates the registered nurse (RN) is responsible for completion of the Discharge Assessment and will need to assess the patient on the day of discharge. If there is a change in the patient ' s condition that will delay discharge, notify the provider immediately.

Review of policy "Catholic Health Nurse Standards of Care for Medical Surgical/Critical Care Units" effective 04/10/17 indicates the RN will conduct a patient assessment at a minimum of every 12 hours. Routine vital signs include temperature, pulse, respirations and blood pressure and are taken every 8 hours, when there is a change in patient condition and/or before transfer to an acute care facility.

Review of the medical record for Patient #1 from 03/27/18 to 04/24/18 revealed Patient #1 was discharged to subacute rehabilitation on 04/24/18 at 04:00 PM. The charge nurse was notified that Patient #1 was dry heaving and nauseous when transferring to the wheelchair for discharge and made the decision to continue the discharge for Patient #1. He was discharged with an emesis (vomit) bag. The last set of vital signs were taken at 01:55 PM. On 04/25/18 Patient #1 was brought back to the facility, admitted to the Intensive Care Unit and intubated (tube inserted in the throat to maintain breathing) for possible sepsis (life-threatening infection).

Interview on 10/03/18 at 02:30 with Staff (A), VP of Patient Care Services and Staff (B), Director of Quality and Patient Safety verfied this finding.