HospitalInspections.org

Based on policy review, document review, medical record review and interview, the hospital failed to adequately implement a discharge plan to address post hospitalization needs for durable medical equipment for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's policy titled, "Discharge of the Patient" revised on 11/8/2021 revealed, "...Purpose: To assist and facilitate discharge of patient...A physician's order is required for the discharge of a patient...All patients will have a discharge instruction sheet completed and reviewed by the Patient and/or family prior to discharge...Discharge to Home...Complete and review the discharge record with the patient/family prior to discharge, including but not limited to discharge care, medications, follow up appointments...Give all printed discharge instructions and prescriptions to the patient/family if applicable..."

Review of the hospital's policy titled, "7D Pulmonary Medical-Surgical Unit Admission/Discharge Criteria, A-09m" revised on 9/27/2022 revealed, "...Criteria for Patients to be discharged to home...Discharge plan in place...Referrals made for aftercare as appropriate..."

2. Review of the Job Description for Registered Nurse (RN)- Case Manager effective 9/4/2022 revealed, "Responsibilities...Acts as a resource for adequate medical record documentation, level of care recommendations, and services as they relate to diagnoses, and treatment options for post-discharge care..."

Review of the Job Description for RN-Medical Surgical (Med Surg) effective 8/22/2021 revealed, "...Responsibilities...Assesses and coordinates patient's discharge planning needs with member of the healthcare team..."

3. Medical record review revealed Patient #1 was admitted to the hospital on 8/16/2023 with diagnoses which included Acute Dyspnea/Hypoxia and Interstitial Lung Disease. (Dyspnea is shortness of breath. Hypoxia is not having enough oxygen. Interstitial lung disease (ILD) is a group of disorders that causes progressive scarring of lung tissue.) The patient was a non-smoker and had a past medical history significant for Asthma.

Review of the History and Physical dated 8/16/2023 revealed, "...67yo [year old] female with hx [history] of asthma, hypertension...presents due to dyspnea...has been having follow up appointments for possible lung nodules...more short of breath since January...worse with exertion...She is having wheezing, especially at night time, with minimally productive cough. In the ER [Emergency Room] she was hypoxic requiring 5 L NC [liters of oxygen via nasal cannula]...Assessment/Plan...Dyspnea Interstitial Lung Disease suspected...Hx of asthma - CXR [chest x-ray] consistent with ILD- had outpatient CT [computerized tomography] at her pulm [pulmonologist]...cannot access - will consult pulm [pulmonary tomorrow and follow up on CT scan [Pulmonary medicine is a medical specialty that deals with diseases involving the respiratory system]...duonebs [DuoNeb combines ipratropium and albuterol to treat chronic obstructive pulmonary disease. It works by opening the airways and reducing inflammation in the lungs. This medication requires the use of a nebulizer, a machine that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask.]...Home Medications: No medications documented...Admit to inpatient..."

Review of the Pulmonary Rehab Current Functional Level dated 8/17/2023 at 9:37 AM revealed, "Level 3: Able to walk 150-300 Feet at Medium Pace...Does Not Meet Criteria for Pulmonary Rehabilitation..."

Review of the Pulmonary Consultation Note dated 8/17/2023 at 3:24 PM revealed, "...Asked to see patient...for evaluation and management of hypoxemia. I reviewed clinic note from yesterday where it appeared that patient got into the body box to do her pulmonary function test and had acute shortness of breath and thereafter found to have hypoxia...She does not smoke. She does use a vaping pen...She reports that 2 breathing treatments she received here helped significantly...she does not require exertional supplemental oxygen...I personally reviewed her CT chest ordered yesterday and compared to 2020. There is [has] been no change in her pulmonary fibrosis. She has peripheral fibrosis primarily with interstitial fibrosis...If we believe the numbers yesterday that were reported this seems to be a case of transient hypoxemia. The dyspnea improved with bronchodilators..."

Review of the Pulmonary Function Report dated 8/17/2023 at 4:35 PM revealed, "...She [Patient #1] had breathing tx [treatment] prior to testing...Full Pulmonary Function Test: 1. No evidence of obstruction...Normal lung volumes with a total lung capacity of 4.16 liters, 83% [percent] predicted. 3. Moderate diffusion impairment...although corrects to normal when corrected for alveolar volume..."

Review of the Care Management note dated 8/18/2023 at 12:01 PM revealed, "...Pulmonary consult completed. Pt [patient] satting at 100% [percent] on 3L O2 NC [3 liters of Oxygen via nasal cannula]. No therapies ordered at this time. No needs. CM [Case Manager] to follow..."

Review of the Inpatient Clinical Summary dated 8/18/2023 at 6:23 PM revealed, "...Diagnoses This Visit CKD (chronic kidney disease)...Current vaping on some days...Hyperlipidemia, unspecified...Hypoxemia...Pulmonary Fibrosis [Pulmonary fibrosis is a lung disease that occurs when lung tissue becomes damaged and scarred. This thickened, stiff tissue makes it more difficult for the lungs to work properly and as it worsens, the patient becomes progressively more short of breath.]...Shortness of Breath...Follow up with primary care provider In 2 weeks...Pulmonology office will call you on Monday [8/21/2023] to schedule a follow up to review your breathing and your heart test...Discharge Medication List: New Medications Other Medications albuterol-ipratropium (DuoNeb) 3 Milliliter Inhalation Every 6 hours..."

Review of the Inpatient Discharge Instructions dated 8/18/2023 at 6:23 PM revealed, "...Discharge Medication List: Home Medications to Continue...albuterol-ipratropium (DuoNeb) 3 mL, Inhalation, Every 6 hours Next Dose Due [this area was not completed]...No New Medications Given..."

Review of the Discharge Summary completed on 8/19/2023 revealed, "...presented due to dyspnea. She was seeing her pulmonologist...for follow-up in the office and was found to be hypoxic, she was sent to the ER for further evaluation. She had an outpatient CT chest and there was some concern that patient may have interstitial lung disease. Her chest x-ray here did support possible interstitial lung disease. She was seen by pulmonology, who believed that her episode of hypoxemia was transient. Echocardiogram was performed to evaluate for shunt and did show a small atrial level shunt with limited sensitivity. [A shunt is a passage by which blood moves from one area (blood vessel or heart chamber) to another in a pattern that isn't normal.] Pulmonary function testing was performed and did not show any evidence of obstruction, had normal lung volumes with moderate diffusion impairment with DLCO [Diffusing capacity of the lungs for carbon monoxide] of 60%. [DLCO is a measurement to assess the lungs' ability to transfer gas from inspired air to the bloodstream.] CT was reviewed by pulmonology and there is no evidence of pulmonary fibrosis or interstitial lung disease. We will have her follow-up outpatient in pulmonology clinic. She was evaluated by respiratory therapy prior to discharge and did not require any oxygen at rest or with exercise. She was discharged in stable condition...Discharge Medications albuterol-ipratropium (Duo-Neb) 3 Milliliter Inhalation Every 6 hours..."

There was no documentation in the medical record to indicate Patient #1 had been assessed to determine if she had a home nebulizer and no documentation the patient was taught how to obtain and use a nebulizer.

In an interview on 9/19/2023 at 1:25 PM, the hospital's Risk Manager (RM) stated, "They admitted her [Patient #1] and treated her, checked to see if she needed home oxygen but nobody set her up on home nebulizer..." The RM continued and stated when she reviewed the record, "I felt like there was an on opportunity for improvement. They [hospital staff] should have asked to see if she had a home nebulizer." The RM was asked who should have assessed the patient to see if she had a home nebulizer. The RM stated, "I'm not exactly sure."

In an interview on 9/19/2023 at 1:28 PM, the hospital's Quality Manager, QM verified the patient wasn't assessed for the home nebulizer then stated, "It looks like we missed an opportunity here; we need to figure out how to make sure this doesn't happen again...I wish we had a good excuse as to why we didn't do it, but I don't."

In an interview on 9/19/2023 at 1:55 PM, the Discharge Nurse (DN) stated, "When I get this [order for home DuoNeb treatments] it didn't come up as a new medication so her's [Patient #1] showed it was was likely not a new medication..."

In a telephone interview on 9/19/2023 at 3:38 PM, Patient #1's daughter verified the patient didn't have a home nebulizer and no one had asked her if she did before the patient was discharged on 8/18/2023.