HospitalInspections.org

.
Based on review of hospital policies and procedures and interview, the facility failed to ensure the govering board was involved in the grievance process.

Failure to do so creates risk for patient access to the grievance process and may limit patients' ability to exercise rights.

Findings:

1. In review of a policy and procedure titled, "Concerns/Complaints by Patients (Customers)" (Reviewed 2/26/03), it stated that a grievance occurs when a "complainant is not satisfied" with resolution of a complaint. It did not address written complaints (grievances) or other forms of grievances including, but not limited to, neglect and abuse. Additionally, the policy stated that the "Board of Commissioners will be informed of the actions of the [ad hoc] Grievance Committee and provided with data regarding other complaints."

In another policy titled, "Customer Service Representative Role in Customer Complaint Resolution" (Reviewed 5/28/08) item 4. stated, "The Customer Service Representative documents complaints and concerns. A QI [quality improvement] summary is sent quarterly to the Boards and the Quality Director."

2. On 6/25/2015 at 9:50 AM during an interview with Surveyor #3 and the Chief Quality Officer (Staff Member #10), s/he stated that the governing board was not involved in the grievance process. The Quality Officer also stated, the board did not receive quarterly grievance data at the hospital. S/he was not aware if the grievance process/responsibility had been delegated to other facility staff as required.
.

.
Based on review of hospital documents and interview, the facility failed to establish a clearly defined procedure for submission of patients' written or verbal grievance to the hospital.

Failure to do so creates risk to patients' ability to exercise their rights in a grievance process.

Findings:

1. On 6/25/2015 at 9:50 AM during an interview with Surveyor #3 and the Chief Quality Officer (Staff Member #10), s/he stated that there was a patient information booklet in every room titled, "Guide to Guest Services." The booklet contained the phone extension number for "Customer Service Representative". S/he acknowledged there was no written explanation about patient complaints or grievances related to the Customer Service Representative contact information.

2. In review of facility policy titled, "Customer Service Representative Role in Customer Complaint Resolution", item 2 stated, "Information on how to contact the Customer Services Representative/Patient Advocate is listed on the back of the Patient Bill of Rights and Responsibilities [form] that is given to the patient on admission." That information could not be located by Surveyor #3 and #6 on the back of the form.

3. A review of a blue orientation packet provided to all inpatients upon admission titled,
"Samaritan Healthcare", did not contain information about the grievance or complaint process.

4. On 6/25/2015 between 1:00 - 1:30 PM Surveyor #6 interviewed patients about their knowledge of the grievance process. Three of five patients (Patients #3, #4 and #5) could not identify the patient grievance process.
.

.
Based on interview and document review, the hospital failed to demonstrate that clinical performances of non-employee nursing staff are evaluated by nursing services.

Failure to evaluate the performance of non-employee nursing staff risks provision of ineffective and unsafe care provided to patients.

Findings:

1. On 6/25/2015 at 10:00 AM, Surveyor #4 interviewed the chief nursing officer (Staff Member #12) regarding how agency nursing staff individual performances are evaluated. S/he stated the hospital had drafted an agency nurse orientation policy that included a performance feedback evaluation but had not implemented the policy at the time of survey.

2. On 6/25/2015 at 11:00 AM, Surveyor #4 reviewed agency nurse files and found no documentation of performance evaluations being completed for 2 of 5 files (Staff Member #13, #14).

.
Based on observation, review of hospital policy and procedure and interview, the facility failed to follow the patient identification process prior to medication administration for 1 of 1 infant patient (Patient #10).

Failure to do so may result in patient care errors based upon patients being mis-identified.

Item #1 - Patient Identification

Findings:

1. In review of facility policy titled "Patient Registration" (Revised 5/18/12) on page 2 of 7, item C.1. stated "The Admitting Clerk will armband the patient ...For a child the armband can be placed on the leg."

Another policy titled, "Patient Identification" (Effective 10/20/08) stated in the 2nd paragraph on page 1 , "The identification band must remain physically attached to the patient at all times in order for staff to confirm the identity of the wearer... " In the section under "Staff Responsibilities" it stated, "Staff allocated for the care of patients on a shift are responsible for ensuring that each patient has an armband. Any staff finding an armband that is...missing...is responsible to replace it immediately...Except in an emergency no procedure is to be done when the patient's identity cannot be verified by the armband."

In review of the policy titled, "Medication Administration to Patients" (Revised 10/08/13) item 1 stated in bold lettering, "IT IS IMPORTANT when administering medication to remember the 7 RIGHTS". The policy listed the 7 rights which included one as the "Right Patient."

2. On 6/23/2015 at 10:00 AM, Surveyor #3 interviewed the mother of a 1 month-24 day old infant on the medical-surgical unit. Patient #10 was admitted for failure to thrive and inability to maintain adequate oral nutrition. The infant was vomiting and was not taking an adequate amount of formula at home. The patient was admitted to receive supplemental nutrition, as well as medications through a feeding tube ( tube inserted through the nose and into the stomach). The patient had been receiving 3 types of oral medications and antibiotic eye drops during her/his stay.

3. On 6/23/2015 at 10:00 AM, Surveyor #3 observed a nurse (Staff Member #15) carry medications into the room for administration via the feeding tube to the infant . The Surveyor observed the infant did not have an identification band on as required by policy. The nurse electronically scanned the armband attached to the bassinette in the room and administered medication.

It was eventually determined that infant-sized identification badges were not available for staff use on the medical-surgical unit (only adult sized bands).

Item #2 - Safe Injection Practices

Based on observation, staff failed to adhere to safe injection practices for 1 of 1 patients observed (Pateint #6).

Failure to do so creates risk for the transmission of infectious organism and/or diseases to patients.

Reference: Centers for Disease Control and Prevention, Medication Preparation Questions, Updated March 2, 2011; "Parenteral medications should be accessed in an aseptic manner...Proper hand hygiene should be performed and the rubber septum should be disinfected with alcohol prior to piercing it."

Findings:

On 6/24/2015 at 10:30 AM, Surveyor #3 observed a nurse (Staff Member #16) prepare an injectable medication for administration to Patient #6. The patient was in the Advanced Care Unit and required intravenous medication to aid kidney function. The nurse removed the dust cover from 2 vials and did not disinfect each vial with alcohol prior to inserting a needle into the rubber diaphragm.

The facility was unable to locate a policy directing nursing staff in handling injectable medication vials.

.
Based on document review, interview, and review of hospital policy and procedure, the hospital failed to follow its procedure regarding access to medications when the pharmacy is closed.

Failure to follow after pharmacy hours access procedures risks patient safety, medication accountability and security.

Findings:

1. Review of the hospital's policy titled "Obtaining Medications After Pharmacy Hours" (Revised 3/23/2010) read in part: "Each night at closing of the department, a key to the supply of medications is signed out to the House Director. The House Director is then responsible for the supply of medications. . . Each morning, the key to the supply of meds must be signed back to the pharmacist."

2. On 6/24/2015 at 10:40 AM during a tour of the pharmacy, Surveyor #4 reviewed the key control log for the external pharmacy for the past 54 days and found 16 days between 5/1/2015 and 6/24/2015 in which there was no evidence that pharmacy and nursing staff signed for pharmacy keys.

3. On 6/24/2015 at 11:00 AM, Surveyor #4 interviewed the Director of Pharmacy (Staff Member #17) regarding after-hours access procedures to pharmacy. S/he acknowledged the procedure had changed recently and compliance with signing for keys was less than optimal.

.
Based on review of hospital policy and procedure and record review, the facility failed to assure completion of a nutrition assessment for an infant by a registered dietician as required per policy.

Failure to do so creates risk that patients identified at higher nutrition risk may not receive required nutrition services.

Findings:

1. In review of the hospital's policy titled, "Interdisciplinary Admission Assessment and Reassessment " (Revised 6/06/14) on page 5 of 8 under "Nutrition Services" it stated, "Nutrition screening is conducted on all inpatients as part of Nursing's Admission assessment...Nutritional assessment is the comprehensive analysis of nutritional risk factors of patients at high nutritional risk in order to initiate appropriate treatment and intervention to maintain or improve nutritional status".

Another hospital policy titled, "Nutritional Screening/Assessment" (Revised 12/31/13) stated on page 3 of 5 that the dietician "will complete initial nutritional assessment within 48 hours of receiving Nursing's nutrition screen (or within 3 days of admission)" for "High risk or potentially high risk (in addition to nutrition screen criteria)".

2. On 6/23/2015 at 9:45 AM Surveyor #3 reviewed the medical record of Patient #10. The patient was a 1 month-24 day old infant admitted to the hospital for failure to thrive, poor nutrition and vomiting. Nursing staff were aware that the patient was not gaining or maintaining weight during the current hospital stay. The nursing staff completed a nutrition screening on 6/19/2015 at 12:21 PM and determined that the patient required a dietician assessment based on "Unintentional weight loss". The patient's diagnosis (Pediatric Failure to Thrive) also met criteria for high risk nutritional status.

Nursing completed a dietary referral and sent it to the dietary department. However, nearly 4 days later a dietician assessment had not been completed.

3. On 6/23/2015 at 9:45 AM Surveyor #3 interviewed the registered dietician (Staff Member #18) about Patient #10. S/he acknowledged that the nursing screening evaluation indicated a need for a dietary consult and that one had not been completed to date. S/he reported that s/he, as the dietician, did not work over the weekend and s/he was also off the Monday after the weekend (resulting in being off-site for 3 consecutive days).

Subsequently, the dietician completed a dietary evaluation and calculated the infant's growth percentile for age and determined the infant's weight to be in the 2.8th percentile for normal by age (significantly below average [50th percentile]. The patient's dietary assessment was completed on 6/24/2015 (5 days after the referral was sent).

.
Based on observation, interview, and review of hospital policies and procedures, the hospital failed to develop and implement emergency fuel and water supply plans/agreements to ensure the safety and well-being of patients during emergency situations and/or events.

Failure to develop and implement emergency fuel and water preparedness plans places the safety of patients, staff, and visitors of the facility at risk during non-medical emergencies.

Findings:

On 6/23/2015 at 11:24 AM, Surveyor #2 reviewed the hospital's emergency preparedness plan and interviewed the facilities director (Staff Member #7) about emergency plans for fuel and water. The facilities director reported that the facility did not have plans or agreements for fuel and water during non-medical emergency events facing the facility and/or local community.

.
Based on observation, interview, and review of hospital policy and procedure, the hospital failed to ensure that patient care supplies did not exceed the manufacturer's designated expiration date.

Failure to ensure patient care supplies do not exceed their expiration dates risks deteriorated and contaminated supplies being available for patient use.

Findings:

1. The hospital policy titled "Emergency Equipment" (Revised 6/10/2011) read in part: "2. Intubation Cart/Difficult Airway Care: a. Cleaning, stocking, and checking shall be performed at the prescribed times by staff."

2. On 6/23/2015 at 1:35 PM in the operating room, Surveyor #4 found the following items in the difficult airway cart: one emergency cricothyroidotomy kit with an expiration date of 1/2014; one portex emergency cricothyroidotomy kit with an expiration date of 4/2013; and three fiber optic bronchoscope swivel adapters with an expiration date of 5/2014.

3. On 6/23/2015 at 1:35 PM, Surveyor #4 interviewed the operating room charge nurse (Staff Member #19) who acknowledged that the difficult airway cart was not part of the monthly operating room outdate checklist.
.

.
Based on observation and interview, the hospital failed to fully implement the requirements of the 2013 Food and Drug Administration Food Code.

Failure to comply with food service codes puts patients, staff, and visitors of the facility at risk from food borne illnesses.

Findings:

1. On 6/24/2015 at 11:03 AM, Surveyor #2 used a thin-stem thermometer to determine the cold holding temperature of tomatoes from the salad bar. The tomatoes were 46.5 degrees Fahrenheit and above the maximum allowable cold holding temperature of 41 degrees Fahrenheit. The dietary manager (Staff Member #8) confirmed this finding at the time of the observation and discarded the tomatoes.

2. On 6/24/2015 at 11:07 AM, Surveyor #2 used a thin-stem thermometer to determine the hot holding temperature of hamburgers from the service line. The hamburgers were 129.5 degrees Fahrenheit and below the minimum allowable hot holding temperature of 135 degrees Fahrenheit. The dietary manager (Staff Member #8) confirmed this finding at the time of the observation and discarded the hamburgers.

Reference: 2013 Food and Drug Administration Food Code 3-501.16
.

.
Based on observation, review of hospital documents and interview, the hospital failed to provide staff direction about cleaning patient care equipment between patients.

Failure to do so creates risk for transmission of infectious organisms and development of possible infectious diseases.

Item #1 - Stethoscope

Findings:

On 6/24/2015 at 10:30 AM Surveyor #3 observed a respiratory therapist (Staff Member #22) on the Advanced Care Unit provide care to Patient #8. The respiratory therapist administered a nebulizer treatment and then listened to the patient's lungs before and after the treatment. The therapist touched other items (i.e. computer, oxygen tubing) before and after using the stethoscope in the room. After exiting the patient's room, the therapist did not clean her/his stethoscope before entering another patient's room.


33674


Item #2 Product Contamination

Based on observation and interview the facility failed to prevent contamination of product before patient care.

Failure to follow manufacturer's instructions for use places patients at risk for nosocomial infections.

Reference: In review of FDA Guidelines, "FDA Safety Communication: UPDATE on Bacteria Found in Other-Sonic Generic Ultrasound Transmission Gel Poses Risk of Infection Date Issued: June 8, 2012" Stated in part, "Be aware that once a container of sterile or non-sterile gel is opened, it is no longer sterile and contamination during ongoing use is possible... Never refill or "top off" containers of ultrasound gel during use. The original container should be used and then discarded".

Findings:

On 06/23/2015 at 10:00 AM, Surveyor #1 observed "Aqua Sonic Gel" bottles stored in the warming unit in the ultra sound exam room #1. Surveyor #1 interviewed an ultra sound technician Staff Member #1 on the use of the ultra sound gel bottles. The technician stated that the bottles are refilled once then discarded.

Item #3 Physical Therapy Equipment

Based on observation and review of hospital's policy and procedures the hospital staff failed to ensure disinfection of the physical therapy equipment (Hydrocollator).

Failure to disinfect equipment places patients at risk for nosocomial infections

Findings:

1. The hospital policy and procedure titled, "Hydrocollator Temperature Monitoring & Cleaning" policy number: 7200-H-3 (effective date: 4/12/2012) stated in part, "Drain and Clean the Tropic Heater twice monthly per manufacturer's recommendations..."

2. On 06/23/2015 at 2:30 PM, during a tour of the physical therapy department, Surveyor #1 interviewed the physical therapy department manager (Staff Member #2) regarding the cleaning and disinfecting of the hydrocollator. The physical therapy manager stated that the hydrocollator is cleaned monthly. A review of the physical therapy cleaning logs from January to June of 2015 revealed that the hydrocollator had been cleaned only one time in the month of May and not twice a month as per hospital policy.

Item #4 Hand Hygiene

Based on observation and review of hospital policies and procedures the hospital failed to ensure that staff members performed hand hygiene according to hospital policy and accepted standards of care.

Failure to perform proper hand hygiene can put patients at risk for health care-associated infections and potentially spread infections in hospitals.

Findings:

1. The hospital's policy and procedure entitled "Exposure Control Plan Overview" (Policy #8770.102; Reviewed 4/23/2015) read in part as follows: "A. Hand antisepsis. Perform hand antisepis: When coming on duty; . . . Before and after patient contact; After glove removal; When hands are visibly soiled; After touching blood, body fluids, secretions or excretions; After touching contaminated items; After touching inanimate objects in the patients immediate vicinity; . . .Before handling an invasive device; before handling medication." CONTACT PRECAUTIONS (In addition to Standard Precautions) Everyone must: Clean hands when entering or leaving room."

a. On 06/24/2015 at 9:45 AM, Surveyor #1 observed a physician (Staff Member #3) on two occasions exiting patient's room, room #2214 and #2225 without performing hand hygiene. Both rooms had signage outside the room for "standard precautions" which stated, "Everyone must clean hands when entering and leaving room".

b. On 6/24/2015 at 10:30 AM, Surveyor #3 observed a nurse (Staff Member #16) prepare injectable medication for administration to Patient #6. The patient was in the Advanced Care Unit and required intravenous medication for kidney function. Just prior to entering the medication room and preparing medications, s/he answered the telephone (a high touch object) at the nurses station. S/he did not perform hand hygiene subsequent to and prior to preparing medications for intravenous administration.

c. On 6/25/2015 at 8:40 AM in the acute care unit, Surveyor #4 observed a registered nurse (Staff Member #23) preparing for an insertion of a central line. Staff Member #23 utilized an ultrasound machine to assess Patient #8's arm for vein viability and then removed his/her gloves without performing hand hygiene. Next, s/he reached inside the trash container to pull it closer to the patient's bed and proceeded to dispose of previously used patient care items. The registered nurse exited the patient's room without performing hand hygiene and retrieved a central catheter kit from another clinical area. S/he re-entered Patient #8's room without performing hand hygiene, donned a pair of sterile gloves, and established a sterile field.

On 6/25/2015 at 9:00 AM, Surveyor #4 interviewed Staff Member #23 who acknowledged s/he failed to performe hand hygiene after patient contact, after glove removal, and prior to handling an invasive device.

2. The hospital's policy and procedure titled "Surgery Procedure Rooms" (effective date: 10/30/09) read in part: "Procedure: C. Wash hands and put on personal protective equipment and as necessary, gloves, safety goggles, etc.; Safety: C. Always wear gloves for protection.; Clean up: D. Remove gloves and wash hands."

a. On 6/23/2015 at 2:55 PM during a terminal cleaning of operating room #5, Surveyor #2 observed a turnover technician (Staff Member #5) grab the rim of a full garbage cart with his/her bare hands and pull it out of the operating room. The technician did not perform hand hygiene after removing the garbage cart from the operating room. The technician then left the operating room area and did not wash his/her hands.


Item #5 Function Test for Ultrasonic Dishwasher

Based on observation and record review, the hospital staff failed to follow manufacturer's instruction when using "SonoCheck" a function test to ensure that the ultrasonic dishwasher is cleaning properly.

Failure to follow manufacturer's instructions for use when testing the ultrasonic dishwasher places patients at risk for disease transmission.

Reference: Instructions for use for SonoCheck (reviewed 2015-06-01) stated in part: "1. Prepare a bath of cleaning solution in compliance with instructions for use by the sonic manufacturer and the detergent manufacturer. 2. De-gas the bath in accordance with ultrasonic manufacturer's instructions. 3. Insure that the bath is within the proper temperature range as provided by the detergent manufacturer."

Findings:

On 06/24/2015 at 8:45 AM during a tour of the sterile processing decontamination room, Surveyor #1 observed a central sterile technician (Staff Member #4) placing medical instruments with 2 vials of testing devices "SonoCheck" into the ultrasonic dishwasher. When the ultrasonic dishwasher completed its cycle, the technician placed the vials on the counter. Surveyor #1 observed no change in color within the vials. Surveyor #1 asked the technician if the testing devices had passed, s/he stated they were not sure. Both the technician and Surveyor reviewed the ultrasonic dishwasher instructions, and it states in part that the testing vials should have turned from blue/green to yellow after a specified time. After reviewing the instructions, the technician failed to follow steps as outlined to ensure proper cleaning.


33900


Item #6 - Cross Contamination

Findings:

On 6/23/2015 at 3:22 PM during a terminal cleaning of operating room #5, Surveyor #2 observed an environmental services technician (Staff Member #6) place an open bucket of cleaning solution on top of a cart that had sterile supplies on it (bandages, tape, gloves, iodine). The technician then proceeded to clean operating room equipment with cloths that s/he dipped in the cleaning solution. During this process, the sterile supplies were splashed with the cleaning solution.


35197


.

.
Based on record review, interview and review of hospital policies and procedures, the hospital failed to ensure hospital staff members followed admission assessment screening identifying patients in need of actual or potential post discharge needs as outlined in hospital policy for 2 of 4 medical records review (Patients #1 & #2).

Failure to identify patient's post discharge planning needs at an early stage of their hospitalization could lead to unidentified post-hospital health care services or unavailability of family to provide follow up care in the home.

Findings:

1. The hospital's policy and procedure entitled "INTERDISCIPLINARY ADMISSION ASSESSMENT AND REASSESSMENT" (ID # 8720-A-10) (Revised 6/06/2014) read in part as follows: "ADMISSION ASSESSMENT: An admission assessment in the Electronic Medical Record (EMR) will be completed on all patients upon admission to Samaritan Hospital with the exception of patients hospitalized for observation status... COMPONENTS OF THE ADMISSION ASSESSMENT: Vital Signs ...Functional Assessment, Abuse/Neglect Assessment, Discharge planning considerations ...Each patient's actual and potential needs pertaining to post discharge will be assessed. A Discharge consideration screen will be completed as part of the interdisciplinary admission assessment and discharge needs will continue to be assessed and addressed throughout the hospital stay and upon discharge ...CARE MANAGEMENT: A Care management Assessment is indicated when a discharge need is identified and/or when any item is checked in the Care Management Discharge Screen in the EMR ..."

2. On 6/25/2015 at 2:40 PM, Surveyor #5 reviewed the electronic medical records (EMR) of patients admitted as inpatients and discharged during the month of May and June. The record review revealed the following:

a. Patient #1 was a 94-year old patient admitted on 6/22/2015 for acute upper gastro-intestinal (GI) bleeding. The patient's functional assessment (addresses patients ability to perform activities of daily living) detailed on the admission assessment was not not completed in the patient's EMR. Not addressing the functional assessment on admission could lead to missed post-hospital services the patient requires at home following discharge.

b. Patient #2 was a 90-year old patient admitted on 5/22/2015 for left leg acute deep vein thrombosis. Similar findings were revealed in Patient #2's medical record.

3. On 6/25/2015 at 11:00 AM, an interview with Surveyor #5 and the hospital's Care Management Supervisor (Staff Member #9) confirmed the missing documentation.

.
Based on interview and review of hospital policies and procedures, the hospital failed to ensure hospital discharge planning policies and procedures reflected current discharge planning processes.

Failure to have hospital discharge planning policies and procedures which reflect current discharge planning process can lead to an outdated process that cannot identify post-hospital patient needs and potiential for hospital readmissions.

Findings:

1. The hospital's policy and procedure entitled "Policy Development and Maintenance" (ID # 8610-P-11) (Revised 7/9/10) read in part as follows: "POLICY: To provide a method of providing effective and structured organizational policies ...C. Policy Management 1. Policies are to be reviewed every 3 years. Policies dated older than three years will be considered out of date. Standards of practice may require some policies to be updated more frequently than every three years. Policies that do not reflect current standards of practice will be considered out of date."

2. During an interview on 6/23/2015 at 1:20 PM, with the hospital's Care Management Supervisor (Staff Member #9), Surveyor #5 was handed a policy and procedure entitled "DISCHARGE PLANNING" (ID 8720-D-2) and observed the document's revised date as "3-03-11" The policy outlines the discharge planning process regarding information gathering, reading the medical chart, interviewing the patient (including family as applicable) and documenting on an "EMR Discharge Planning Assessment." On page 4, it reads "E. Fill out the Discharge Planning Department's Discharge Instruction Sheet ..." Upon further review, the policy does not include a detailed process for either social worker or case manager involved in discharge planning. The Care Management Supervisor stated that the "EMR Discharge Planning Assessment" form and the "Discharge Planning Department's Discharge Instruction Sheet" currently are not used. S/he confirmed the hospital's discharge planning policy is outdated and is overdue for review and update.

.
Based on medical record review, the hospital failed to demonstrate implementation of discharge plans for 1 of 1 patient discharge plans reviewed (Patient #9).

Failure to implement discharge plans for patients creates risk for potential readmission to the hospital .

Findings:

1. In review of facility policy titled, "Discharge Planning" (Revised 3/03/11) it described the discharge planning process. On page 4 of 4 under item E. it stated, "Fill out the Discharge Planning Department's Instruction Sheet. Go over with patient/family and give them a copy. Fill out this form on all patients who have ...D.M.E. [durable medical equipment] ...This form is to be used to educate and inform the patient/family of discharge referrals and arrangements to aid in continuity of care post-discharge".

2. In review of the medical record of Patient #9, it was noted that the patient was admitted on 5/27/2015 and discharged on 5/28/2015. The patient was a 2 month 23-day infant who had spent 1 month in the neonatal intensive care on a previous admission. The infant was admitted for hypoxia (poor blood oxygenation) and had 2 congenital heart defects (tears in 2 locations in the heart that lead to poor blood oxygenation). An order for discharge to home was written on 5/28/2015 and the patient's supplemental oxygen was removed at 7:55 AM. The discharge plan included a requirement for in-home oxygen therapy and other equipment for continuous blood oxygenation monitoring.

A note entered in the medical record on 5/28/2015 at 9:08 AM; "Resp [respiratory therapy] called about the home oxygen set-up." However, there was no documentation in the medical record confirming oxygen therapy and monitoring had been arranged with the vendor. The
"Discharge Plan" [instruction sheet] signed by the parents at 6:25 PM provided information about the name of the oxygen vendor and a contact phone number, as well as oxygen flow rates and indications. The medical record indicated that the patient was discharged from the hospital with family at 6:25 PM.

The last note in the medical record on 5/28/2015 at 6:26 PM by a nurse (Staff Member #16) indicated that the oxygen therapy company was "to be called for home oxygen and monitoring" and it did not indicate who was responsible for implementing the plan. There was no indication in the medical record that the parents had been instructed to arrange for in-home oxygen therapy or educated about how to safely use oxygen equipment. An "addendum" note by a physician entered in the chart at 6:05 PM indicated that the patient had some difficulty breathing (including lower blood oxygen readings) while feeding and sleeping.