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Based on record review, document review and staff interview it was determined the facility failed to document rationale for discontinuation of home medications in one (1) out of one (1) clinical records reviewed (Patient #1). This failure has the potential to cause harm to all patients who may be taking home medications.

Findings include:

1. A review of Patient #1's clinical record revealed a History and Physical conducted on 3/9/19 at 5:45 a.m. listed home medications including Eliquis, Flomax, and Neurontin. A document in the clinical record titled 'Hospitalist Progress Note', dated 3/9/19 at 4:13 p.m., listed the medications along with Lasix as home medications. The patient's clinical record revealed the medications were not ordered to be given while he was an inpatient. A rationale for not continuing Eliquis was contained in a documented titled, "Hospitalist Progress Note" dated 3/9/19 at 4:18 p.m. which stated oral anticoagulants were being held secondary to low hemoglobin. No rationale was given in the clinical record for not continuing his other home medications including Flomax, Lasix, and Neurontin.

2. An interview was conducted on 4/10/19 at 12:55 p.m. with the Chief Medical Officer. He stated his expectation is the hospitalist would note in the History and Physical the home medications and rationale for the discontinuation of any of those medications.

Based on record review, document review and staff interview it was determined the facility failed to provide discharge instructions, including complete discharge medication instructions, for seven (7) out of thirty (30) patients to prepare them for post-hospital care (Patients #1, 17, 19, 22, 23, 24, 30). This failure has the potential to cause harm to all patients.

Findings include:

1. A review of Patient #1's clinical record revealed on discharge he was given a document titled, "Patient Summary Discharge Instructions, Orders and Medications". Discharge orders were placed for a Trilogy machine, oxygen (O2), and a cardiac diet. The patient's clinical record revealed no documentation an assessment was completed to determine if he understood instructions related to use of the Trilogy machine or how to obtain portable O2 through the Veteran's Administration (VA); no documentation the patient was offered the opportunity to obtain portable O2 through a vendor, which he would pay for privately until the VA could provide him with O2; and, no documentation of education being provided on the cardiac diet.

2. A review of documents from Appalachian Medical for Patient #1 revealed the patient began using the Trilogy machine on 3/15/19 after receiving education by the vendor. Documents from the company revealed the patient did not use his Trilogy machine on 3/16/19 (Saturday) or 3/17/19 (Sunday). Records revealed the company provided re-education on 3/18/19 (Monday) to the patient and his niece about use of the Trilogy machine. Records revealed the machine was used every day thereafter from 3/18/19 through 4/8/19.

3. A review of clinical records for Patients #1, 17, 19, 22, 23, 24 and 30 revealed the records contained incomplete discharge medication instructions. The records revealed no education was performed on times/dates of last doses of medications administered.

4. An interview conducted on 4/9/19 at 10:10 a.m. with the Social Worker Manager revealed Patient #1 was discharged on Saturday (3/16/19) with an order for continuous O2. She stated the patient was on an O2 concentrator at night prior to his admission and would have been expected to contact the VA to obtain portable O2 on Monday (3/18/19). She acknowledged the patient's clinical record did not reflect he was educated on how to obtain portable O2 through the VA, and they sometimes take up to two (2) days to provide O2 once they are aware of the orders. She further acknowledged the patient may have gone up to four (4) days without portable O2 and would have been homebound during this time. She stated in part, "This is the VA." She also concurred there was no documentation of an assessment completed to ensure he understood the instructions regarding use of the Trilogy machine. During this same interview, she concurred the above noted patients did not receive appropriate medication discharge instructions.

5. An interview conducted on 4/9/19 at 2:35 p.m. with the Clinical Nutrition Services Director revealed upon reading the hospitalist notes for Patient #1, the dietician determined the patient had a grave diagnosis. She stated it would have been unethical to counsel the patient on a cardiac diet by saying in part, "You're dying and you can't have salt." She also stated the dietician deemed education inappropriate but acknowledged the clinical record did not reflect this assessment and the dietician's decision not to proceed with counseling was not conveyed to the Physician.