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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.55 Condition of Participation: Emergency Services was out of compliance.

A-1100 - The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. Based on interviews and document review, the facility failed to ensure patients who required supplemental oxygen were supplied with oxygen prior to discharge from the Emergency Department (ED) in two of two medical records reviewed in which new home oxygen was required. (Patient #2, Patient #4).

Based on interviews and document review, the facility failed to ensure patients who required supplemental oxygen were supplied with oxygen prior to discharge from the Emergency Department (ED) in two of two medical records reviewed in which new home oxygen was required. (Patient #2, Patient #4).

Findings include:

Facility policy:

The Care Coordination - Hospital Discharge/Emergency Department Utilization policy read, the purpose was to ensure all patients who have been treated at the ED receive timely follow up to prevent readmission.

1. The facility failed to ensure patients' home oxygen was set up prior to discharge from the ED.

A. Document Review

a. Medical record review revealed a lack of evidence patients received home oxygen prior to being discharged from the ED.

i. On 7/26/21 at 18:02, Patient #2 arrived at the Emergency Department (ED) with a chief complaint of shortness of breath (SOB) and had a positive COVID test from 7/15/21. According to the ED provider's note, Patient #2 was discharged with home oxygen and was recommended to wear it at all times. According to the provider's home oxygen order, the patient was to wear oxygen at all times.

There was no evidence in the medical record staff arranged home oxygen for the patient before the patient left the emergency department.

ii. On 9/20/21 at 10:32 a.m., Patient #4 arrived at the Emergency Department with a chief complaint of SOB and a had a positive COVID test from 9/9/21. According to the ED provider's note, Patient #4 was to be discharged home on oxygen and was required to wear oxygen at all times.

There was no evidence in the patient's medical record staff arranged home oxygen for the patient before the patient left the emergency department.

b. On 9/21/20 at 1:00 p.m., the facility was requested to provide the policy and procedure for the discharge of patients from the ED requiring home oxygen set-up.

On 9/21/21 at 1:39 p.m., the Director of the Emergency Department (Director) #9 responded by email which read the facility did not have a policy or procedure to specify the process.

B. Interviews

a. On 9/20/21 at 1:15 p.m., an interview was conducted with Registered Nurse (RN) #17. RN #17 stated when a patient was discharged from the Emergency Department on oxygen, the RN was responsible to call and set up home oxygen with the company the patient had chosen. RN #17 further stated the patient remained at the ED until the home oxygen was set up, which sometimes took three to four hours.

b. On 9/22/21 at 3:51 p.m., an interview was conducted Director #9. Director #9 stated when a patient was discharged home on oxygen, the home oxygen order was faxed to the oxygen company to set up the home oxygen. Director #9 stated this occurred before the patient discharged from the ED. Director #9 further stated if the patient was not able to keep their oxygen saturation (a measurement to determine the oxygen level in your blood) above 90%, it was required that the patient received their portable oxygen tank from the home oxygen company prior to their discharge. Director #9 stated if a patient did not receive their home oxygen prior to discharge, there was a risk the patient could develop hypoxia (an absence of enough oxygen to sustain bodily functions) and experience other symptoms such as fainting.