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Based on record review and interview, the facility failed to ensure a registered nurse supervised and evaluated each patient care, in that,

the RN failed to ensure Patient #1 (1 of 10 discharged patients) had a safe discharge on 8/29/2023.

Findings

There was no against medical advice (AMA) for Patient #1 leaving without oxygen.

There was no physician notification of Patient #1 leaving without his oxygen.

There was no physician notification to delay discharge because Trilogy Bipap machine had not been secured and the patient/support person had not been educated/trained on its use.

Patient #1 was discharged prior to delivery, set up, and training/education in the use of a Trilogy Ventilator for Bipap. There was no indication the Trilogy /Bipap was set up at the patients home prior to discharge. There was no documentation the Trilogy machine was solidified prior to discharge. There was no education/training of patient and/or support persons prior to patient discharge for the setup and use of the Trilogy Bipap machine.

Patient #1 was not provided a list of all medications the patient should be taking after discharge, with clear indication of changes from the patient's preadmission medications. The 8/29/2023 Discharge instructions received by Patient #1 did not list oxygen medication changes including dose, and delivery via Trilogy Bipap.

Patient #1 was discharged without oxygen to use during transportation home.

Patient #1's 8/18/2023 record reflected an order for continuous oxygen and an order for home Bipap.

~ 8/29/2023 Pulmonary Progress Note: Bipap ordered for home, case management is consulted. He is using Bipap overnight, blood gases have shown persistent awake hypercapnia.

~ 8/29/2023 19:20 PM Nurse Note: Patient discharge delayed because patient's ex-wife forgot to bring patients 02 with her. She attempted to take hospitals O2 with her and I notified her that we could not do that. She asked if we could just rent her a tank. I notified her that she would have to go home and get the oxygen prior to discharge. Patient decided that he could make it home with no oxygen in use; stated that oxygen is at house. Charge nurse is aware. Pt discharged to home at this time.

During record review and interview on 8/31/2023 ending at 1:43 PM, Personnel #6 navigated the record and Personnel #1 was present. They were asked for the oxygen changes on the Discharge instructions and signature. They confirmed the oxygen and Trilogy/Bipap changes were not included on the instructions. They were asked if the patient discharged without oxygen. They confirmed the patient left without oxygen. They were asked for an AMA (against medical advice) and physician notification. They confirmed they were not documented. They were asked for the education for the Trilogy. They confirmed it was not documented. They were asked for documentation of Trilogy approval and receipt. They confirmed it was not documented.

Oxygen Therapy At Home: Tips for Using Oxygen In Your Home (webmd.com)
Oxygen is a prescription medication.

Oxygen Treatment for Chronic Obstructive Pulmonary Disease (COPD) (webmd.com)
Don't stop therapy or make changes on your own without first talking with your doctor.

BiPAP: How It Works, Benefits, and BiPAP vs Other Machines (webmd.com)
Bilevel positive airway pressure machine, a BiPAP may be a better choice if you need more help breathing because of severe sleep apnea or a condition like congestive heart failure.

Based on record review and interview, the facility failed to ensure implementation of a safe discharge plan during the hospitalization to include post discharge transportation and care, in that,

~ Patient #1 (1 of 10 discharged patients) was discharged prior to delivery, set up, and training/education in the use of a Trilogy Ventilator for Bipap.

~ Patient #1 (1 of 10 discharged patients) was not provided a list of all medications the patient should be taking after discharge, with clear indication of changes from the patient's preadmission medications.

~ Patient #1 (1 of 10 discharged patients) was discharged without oxygen to use during transportation home.

Findings

Patient #1's 8/18/2023 record reflected an order for continuous oxygen and an order for home Bipap.

~ 8/29/2023 Pulmonary Progress Note: Patient overall is doing well. He is on low flow baseline supplemental oxygen...blood gases show compensated mild hypercapnia...Acute on Chronic hypoxic and hypercapnia respiratory failure...Right lower lobe atelectasis ...Pleural effusion...Chronic COPD...Suspected aspiration...Bipap ordered for home, case management is consulted. He is using Bipap overnight, blood gases have shown persistent awake hypercapnia.

~ 8/29/2023 Discharge instructions received by Patient #1 did not list oxygen medication changes including dose, and delivery via Trilogy Bipap.

~ 8/29/2023 19:20 PM Nurse Note: Patient discharge delayed because patient's ex-wife forgot to bring patients 02 with her. She attempted to take hospitals O2 (oxygen) with her and I notified her that we could not do that. She asked if we could just rent her a tank. I notified her that she would have to go home and get the oxygen prior to discharge. Patient decided that he could make it home with no oxygen in use; stated that oxygen is at house. Charge nurse is aware. Pt discharged to home at this time.

The post discharge plan included continuing with the same home services but adding newly ordered Bipap. Orders for this triggered insurance approval process for a Trilogy portable home ventilator.

There is no documentation of the execution of the post discharge plan. There was no indication the Trilogy /Bipap was set up at the patients home prior to discharge. There was no documentation the Trilogy machine was solidified prior to discharge.

There was no education/training of patient and/or support persons prior to patient discharge for the setup and use of the Trilogy Bipap machine.

During record review and interview on 8/31/2023 ending at 1:43 PM, Personnel #6 navigated the record and Personnel #1 was present. They were asked for the oxygen changes on the Discharge instructions and signature. They confirmed the oxygen and Trilogy/Bipap changes were not included on the instructions. They were asked if the patient discharged without oxygen. They confirmed the patient left without oxygen. They were asked for an AMA (against medical advice) and physician notification. They confirmed they were not documented. They were asked for the education for the Trilogy. They confirmed it was not documented. They were asked for documentation of Trilogy approval and receipt. They confirmed it was not documented.

Oxygen Therapy At Home: Tips for Using Oxygen In Your Home (webmd.com)
Oxygen is a prescription medication.

Oxygen Treatment for Chronic Obstructive Pulmonary Disease (COPD) (webmd.com)
Don't stop therapy or make changes on your own without first talking with your doctor.

BiPAP: How It Works, Benefits, and BiPAP vs Other Machines (webmd.com)
Bilevel positive airway pressure machine, a BiPAP may be a better choice if you need more help breathing because of severe sleep apnea or a condition like congestive heart failure.