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Based on observation, review of medical records (MR), staff interview, and review of facility documents, it was determined the facility failed to ensure that patients are reassessed prior to discharge to identify post-discharge needs (A0802). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients.

On 3/13/2025 at 1:45 PM, an IJ was identified for the facility's failure to ensure the safe discharge of patients by reassessing patients' needs prior to discharge. On 3/13/2025 at 4:00 PM, the IJ template was presented to the administration and a removal plan was requested. On 3/14/2025 at 12:31 PM, an acceptable removal plan was received. The facility implemented the following to address the IJ: All Transition Coordinators and Case Managers who facilitate home oxygen therapy or other discharge needs will be educated on this process and the need to verify process completion prior to discharge. All providers who discharge patients with home needs, including oxygen for example, will be educated on this change in process. Additionally, all providers will assess the patient's durable medical equipment and other needs prior to discharge. All nurses who discharge patients will be provided education on the process of discharging patients who have home discharge needs, including oxygen. Home oxygen and other durable medical equipment needs, if required, will be added to the discharge documentation and confirmed by the nurse upon discharge. The IJ was removed on 3/14/25 at 12:50 PM, after the State Survey Agency verified the full implementation of the removal plan. Condition Level non-compliance remains (A0802).

Cross Reference:

482.43(a)(6): Discharge Planning Process

Based on observation, review of medical records (MR), staff interview, and review of facility documents, it was determined the facility failed to ensure that patients are reassessed prior to discharge to identify post-hospitalization needs in two of 10 medical records reviewed (MR1 and MR8).

Findings include:

Facility policy titled, "Discharge Planning Process - Assessment/Reassessment in Inpatient Areas," reviewed 03/01/2023, stated, "... Evaluation of post-discharge needs of any/all patients identified ... development of an appropriate discharge plan based on the evaluation of the patient ... Changes in the patient's condition may warrant development of a discharge plan for a patient not identified during the initial screening process ..."

On 03/12/25 during the review of the medical record for Patient (P)1, the following was revealed:

P1 was transferred to the facility on 02/09/25 at 5:09 AM, with admitting diagnoses of "Pericardial effusion [primary], Acute hypoxic respiratory failure, likely secondary to COPD [Chronic Obstructive Pulmonary Disease] exacerbation vs [versus] moderate bilateral pleural effusions, Chest pain, A-fib [Atrial Fibrillation], Hyperkalemia, Type 2 diabetes, Cardiac tamponade, Tachyarrhythmia, chronic anemia, Schizophrenia."

A clinical note titled, "Physical Therapy Missed Treatment Note," written by S39 on 02/11/25 at 4:34 PM, stated, " ... Patient did not receive physical therapy today due to: PT attempted, pt [patient] with rapid afib [atrial fibrillation] ... will follow up for PT as appropriate ..." A Physical Therapy note from 02/13/25 stated, "[Patient] admit with pericardial effusion and hypoxic respiratory failure secondary to COPD exacerbation who is functionally high level and should progress quickly. Currently, the pt is limited + DOE [Dyspnea on Exertion] which limited amb [ambulatory] distance ... Recommendations: Return to previous setting/facility without therapy."

A clinical note titled, "Home O2 [oxygen] Eval [evaluation]" completed by S36 on 02/14/2025 at 12:27 PM, stated, "Patient is a fall risk and not stable to ambulate at this time. Home O2 eval complete, patient qualified at rest for 2 lpm [liters per minute]." The PFT [pulmonary function test] flowsheet, completed on 02/14/25 at 12:27 PM by S36, documented the results of P1's Home O2 Evaluation as follows: "Resting SpO2 (Room Air) 86; Resting SpO2 w/ Oxygen 93; Resting O2 Amount L/min 2; Resting Heart Rate 67; Exercise SpO2 (Room Air) N/A (Not Applicable); Exercise SpO2 w/ Oxygen N/A; Exercise O2 Amount L/min N/A; Exercise Heart Rate N/A; Recovery Time (Minutes) N/A."

A clinical note written on 02/14/25 at 4:23 PM by S37 stated, "TC [Transition Coordinator] received the following update from [name of Durable Medical Equipment (DME) supplier]: group home is refusing setup because people sneak in [patient] room and smoke in there. they [group home staff] feel it is a fire hazard." The TC's clinical note stated, "TC will close consult."

On 02/14/25 at 4:40 PM, a Rapid Response was called for P1, whom was in atrial fibrillation with rapid ventricular response. S3 documented a Rapid Response Team note that stated, "... positive for shortness of breath and wheezing ... Lopressor 5mg IV already given ... EKG taken ... will cancel discharge, and keep patient another night for observation ... pulse oximetry 93% on 2L NC [nasal cannula] ... will continue to follow ..."

A clinical note written on 2/15/25 at 3:56 PM by S18 stated, " ... Chest XR [x-ray] on 2/15 with suspected new effusion ... monitor for improvement in respiratory status, patient cannot return to group home with oxygen ..." On 02/15/25 at 4:00 PM, 2L NC was removed from P1, and P1 was placed on room air. P1's pulse oximetry assessments, completed while on room air were as follows:

On 02/15/25:
at 4:00 PM, SpO2 was 91%,
at 4:16 PM SpO2 was 91%,
at 4:44 PM SpO2 was 92%,
at 5:25 PM SpO2 was 93%,
at 7:57 PM SpO2 was 90%,
at 8:21 PM SpO2 was 91%,
at 11:55 PM SpO2 was 94%.

On 02/16/25:
at 1:28 AM, SpO2 was 94%,
at 5:03 AM, SpO2- [not recorded]
at 5:13 AM SpO2 was 95%,
at 7:38 AM SpO2 was 96%,
at 8:05 AM SpO2 was 92%.
at 11:02 AM SpO2 was 94%

The Vital Signs Flowsheet documented the patient's position as "lying" when the vital signs were collected, from 02/15/25 at 4:00 PM to 2/16/25 at 11:02 AM. The medical record lacked evidence of Pulse oximetry assessment of P1 with ambulation while the patient was on room air.

P1's After Visit Summary [AVS], dated and timed 02/16/2025 at 11:19 AM, stated, "Your home oxygen has been ordered with [Name of oxygen delivery company]. Once you are home, please contact [oxygen company] for delivery of home set up ..."

A review of the patient's discharge summary, documented on 02/16/25 at 1:09 PM by S18, indicated P1's discharge diagnoses were as follows: Large pericardial effusion complicated with Atrial fibrillation with Rvr [rapid ventricular response]; Acute COPD with exacerbation; Acute hypoxic respiratory failure .... will wean patient off of oxygen as tolerated ..." S4's nursing note at 12:55 PM stated, "Transport arrived, picked patient up via wheelchair and took [him/her] back to [his/her] group home. The patient was discharged back to [his/her] group home on 02/16/25 at 1:09 PM without supplemental oxygen. The medical record lacked evidence that any additional reassessment was completed with P1 ambulating without oxygen. The medical record for P1 lacked evidence that the patient's post-discharge needs for PT and home oxygen were re-evaluated and met prior to the patient's discharge home.

On 03/12/25 at 10:37 AM, an interview was conducted with S15, regarding patients requiring oxygen when returning to home. S15 stated, "A doctor needs to order a 'Home O2 (oxygen) Evaluation' either a RT [Respiratory Therapist] will complete this evaluation or a Pulmonary Function (PF) Tech. More often than not, the PF tech completes these evaluations. These techs will walk patients up and down the halls, if deemed appropriate. They will also assess the patient's resting vital signs and oxygenation requirements. I believe anyone with an oxygen saturation of 90% or less requires oxygen. From there a doctor would order the home oxygen and contact Case Management (CM) or an Outcomes Manager (OM) to set up the home oxygen for a patient."

On 03/12/25 at 10:50 AM, upon interview S5, stated, "Regarding the Home O2 evaluations these tests are only good for 24 hours before they need to be completed again, for insurance approval purposes. A patient must have an oxygen saturation of 87% or 88% to qualify for home oxygen. The test itself consists of four parts. Resting with and without oxygen, and walking with and without oxygen, if the patient is able to walk. The only way respiratory is notified to do these evaluations is if a provider places an order. There is no automatic reevaluation set up."

On 03/12/25 at 11:18 AM, an interview was conducted with S8. S8 stated, "My day begins by looking at my EPIC [Electronic Medical Record] workflow. One of the tasks I am assigned to do are the provider ordered 'Home O2 evaluations.' I am unsure of what the doctor's criteria is when they order this test. However, this test is insurance driven and the patient must drop to 88% or below with their oxygenation to qualify for home oxygen. This insurance driven test must be completed by a RT. The test itself is good for only 48 hours. There is no automatic reassessment placed. If the doctor doesn't order another Home O2 Evaluation, the respiratory team will not be prompted to do the test."

On 03/12/25 at 10:47 AM, during a telephone interview with S3, it was stated that P1 had a Home O2 Evaluation completed and required oxygen for discharge. However, the group home refused the oxygen due to the fact the patient is a smoker and there were safety concerns with smoking and the oxygen tank.

On 03/12/25 at 11:33 AM, during interview, S7 stated, "In a situation where one day the patient is tested for home oxygen and is approved, but for circumstances out of their control, the patient is kept at the hospital and weaned off of oxygen, we would absolutely do a reassessment of their home oxygen needs prior to discharge." S7 confirmed during the interview that the patient's ambulatory pulse oximetry should be assessed when the patient is ready to discharge. At 11:35 AM, during the interview, when questioned what prompts the decision making of whether a patient needs to be ordered oxygen once they discharge from the hospital, S7 stated that the physician needs to assess the patient and if medically appropriate, will determine how to wean the patient off supplemental oxygen while the patient is admitted. Once the patient is ready to be discharged, S7 confirmed that the respiratory department is involved and conducts an "ambulatory pulse oximetry" test to assess the patient's oxygenation while the patient is stationary (with and without supplemental oxygen) then ambulatory (with and without supplemental oxygen.) If the patient requires oxygen at home, a consultation will be placed with the Transition Coordinator. S7 confirmed that if an oxygen tank cannot be delivered for one reason or another, the patient will remain admitted to the hospital and stated, "Patients should get what they need before they are discharged from the hospital." S7 confirmed that patients are required to be reassessed prior to discharge.

During an interview on 03/13/25 at 12:21 PM, S18 was asked how it is determined that a patient on oxygen in the hospital is safe to discharge without supplemental oxygen. S18 stated that the patient's respiratory rate and oxygen saturation are clinically assessed. When asked how to determine the parameters for "wean as tolerated" for a patient, S18 stated, "Every patient is different, the goal is to optimize the patient." During the interview, S18 did not provide any clarification on what "wean as tolerated" meant.

On 03/13/25 at 12:28 PM, when asked whether the "ambulatory pulse oximetry" test is repeated if supplemental oxygen is discontinued and prior to the patient's discharge, S18 stated, "it's the discretion of the physician to repeat the test." When asked whether P1's ambulatory pulse oximetry should have been reassessed after supplemental oxygen was discontinued and prior to the patient's discharge on 02/16/25, S18 stated that [he/she] was seeking to "optimize" the patient and provided smoking cessation education to the patient, ordered medication "to get fluid off the lungs," and the patient's oxygen saturation on room air was 91-94% at rest. S18 further stated, "This is unfortunate that this patient died, but [he/she] was not a healthy person with multiple comorbidities." S18 confirmed that [he/she] did not place an order for P1 to be reevaluated by a Respiratory Therapist for an ambulatory pulse oximetry prior to discharge. During the interview with S18, when asked if the patient was discharged home with albuterol medication, since the patient was on a scheduled nebulizer treatment during the admission, S1 interjected and stated, "The medication was changed to an inhaler." A review of the patient's medication list revealed that the patient was not prescribed an inhaler upon discharge from the facility on 02/16/25.


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Facility policy titled, "Discharge Planning Process - Assessment/Reassessment" revised 03/01/23, stated, "... 1. Within eight (8) hours of admission, a RN performs a nursing assessment. Patients are screened for discharge planning needs. 2. The Outcomes Manager assigned to patient is responsible for assessing the discharge plans, coordinating the patient's plan of care along with the patient and multidisciplinary team from admission to discharge. Changes in the patient's condition may warrant discharge plan for a patient not identified during the initial screening process. The need for reassessment can be identified by anyone on the multidisciplinary, the patient and/or care partner ..."

On 03/12/25 at 2:00 PM, the medical record of P8 was reviewed in the presence of S6. The following was revealed:

On 03/09/25 at 1:27 AM, P8 arrived to the Emergency Department (ED). At 1:35 AM, an ED Triage Note, entered by S41 stated, "To ED ... for SOB, and CP (chest pain) [with] coughing. Recent dx (diagnosis) and admission for pneumonia ... 87% SPO2 (oxygen saturation) on RA (room air). At 1:36 AM, the following vital signs were documented: "SpO2: 96% ... Oxygen Therapy: Supplemental Oxygen; O2 Delivery Method: Nasal Cannula; O2 Flow Rate: 2L/min (liters)." At 5:39 AM, a History of Present Illness (HPI) was documented by S40 that stated, "[P8] is a 67 y.o. (year old) ... with history of cirrhosis, diabetes, methadone use, [and] presents with over a week of cough, shortness of breath. There is some associated pleurisy ... [P8] presents with persistent symptoms and CTA (Computed Tomography Angiography) chest here showing pneumonia." P8's admitting diagnosis was documented in the medical record as "SOB (shortness of breath)." At 6:53 AM, S42 documented, "[P8] Presenting with shortness of breath and cough found with a lingular opacity [an area of increased density or cloudiness in the lingula, which is the upper left lobe of the lung]. Treating for community-acquired pneumonia along with COPD exacerbation as [he/she] has moderate expiratory wheezing on exam. Wean oxygen as able. May benefit from home oxygen evaluation prior to DC (discharge)."
On 03/11/25 at 9:23 AM, S35 placed an order to "Discharge Patient" which stated, "Pending O2 (oxygen) sats > 90% off nasal cannula [Pending oxygen saturation greater than 90% on Room Air]." S35 ordered a Home O2 Evaluation on 03/11/25 at 11:58 AM. S36 completed the Home O2 Evaluation and at 1:31 PM, the results were as follows: "Exercise SpO2 [oxygen saturation measures the percentage of oxygen in the blood] (Room Air): 88%; Exercise SpO2 with Oxygen: 93%." P8 was discharged on 03/11/25 at 6:55 PM, without oxygen. P8's discharged diagnosis was documented in the medical record as "Lingular Pneumonia."

The patient's After Visit Summary (AVS) was printed on 03/11/25 at 2:42 PM and lacked evidence that the patient was ordered oxygen at home. The discharge summary signed by S35 on 03/11/25 at 9:23 AM, lacked documentation that the results of the "Home O2 Evaluation" was reviewed with S35, prior to discharge.

On 03/12/25 at 2:05 PM, S6 confirmed that the discharge order written by S35 indicated P8's oxygen saturations were to be greater than 90% off nasal cannula, the patient's Home O2 evaluation documented P8's oxygen saturation on room air was 88%, and the patient was discharged home without oxygen on 03/11/25. S6 also confirmed that an Outcomes Manager or Transitions Coordinator consultation was unable to be found within the patient's chart.

On 03/13/25 at 4:15 PM, S17 provided an addendum to the note from 03/11/25 at 9:23 AM by S35, that was created on 03/12/25 at 7:56 PM. This note documented the following statement, "Home O2 eval completed prior to discharge, maintained 93% at rest on RA, 88% with exercise on RA. Goal SpO2 88-92% due to COPD, did not require home O2. Discharged to finish course of antibiotics and steroids." The addendum was completed after the patient was discharged, and the medical record lacked evidence of further communication that the patient met the discharge order criteria of "Pending O2 (oxygen) sats > 90% off nasal cannula" prior to discharge. The addendum was completed after the medical record review with S6 on 03/12/25 and after P8 had already been discharged. The medical record lacked evidence of an order or nursing communication stating P8 had an oxygen goal of 88-92% on room air.