HospitalInspections.org

Based on policy review, record review, and interview, the hospital failed to ensure the discharge planning process effectively assessed and evaluated the respiratory needs for 1 of 9 (Patient 1) patients upon discharge. The failure to assess and evaluate patient care needs at discharge places patients at risk for poor outcomes and/or hospital readmissions.

Findings Include:

The hospital failed to ensure the discharge planning process identified a patient likely to suffer adverse health consequences at the time of discharge for 1 of 9 (Patient 1) patients reviewed. (Refer to Tag A-0800)

Based on record review, document review, policy review, and interview, the hospital failed to ensure the discharge planning process identified a patient likely to suffer adverse health consequences at the time of discharge for 1 of 9 (Patient 1) patients reviewed. This deficient practice has the potential to negatively impact the health and well-being of patients and result in rehospitalizations.

Findings Include:

Review of a hospital policy titled, "Discharge Planning Policy," dated October 2024, showed " ... To identify a process that ensures patients are screened using appropriate criteria, and discharge needs are identified ...The discharge planning process will support patient care across the continuum ... Patients will be screened who may have discharge needs based on such factors such as but not limited to ... diagnosis ... or other high-risk indicators ... Case Management ensures that there is a safe discharge plan in place for the patient ... prior to the patient physically leaving the acute care setting ..."


Patient 1

Review of Patient 1's discharged medical record showed a 67-year-old admitted on 02/01/25 for respiratory failure. Medical history showed chronic obstructive pulmonary disease (COPD) (a progressive lung condition that causes breathing difficulties due to airflow limitation), obstructive sleep apnea (OSA) (sleep-related breathing disorder), chronic hypoxic respiratory failure (an ongoing condition where body tissues do not receive enough oxygen to properly function), and hypercapnic respiratory failure (condition where the body's ability to eliminate carbon dioxide is impaired) with dependence on 4 liters (L) of oxygen (O2) via nasal canula (NC).

Review of a document titled, "History of Present Illness," dated 02/01/25 at 9:57 PM, showed " ... COPD on 4L/NC at home ..."

Review an order dated 02/01/25 at 10:12 PM, showed Patient 1 had an order for oxygen therapy via nasal canula.

Review of a document titled, "Coding Summary" dated 02/01/25 (date of admission) at 4:21 PM through 02/19/25 (date of discharge) at 6:42 PM showed, " ...DEPENDENCE ON SUPPLEMENTAL OXYGEN ..."

Review of a "Physician Attestation," dated 02/14/25 at 4:22 PM, showed that Patient 1 had a diagnosis of "severe oxygen-dependent COPD with hypercapnic respiratory failure."

Review of a document titled, "Hospitalist Discharge Summary," dated 02/19/2025 at 10:17 AM, showed " ... Assessment Acute on Chronic Hypoxic and Hypercarbic [sic] Respiratory Failure (4L NC at baseline) ..."

Review of Patient 1's "Discharge Report," dated 02/19/25 at 10:17 AM, showed that Staff J, MD, documented, "I certify this patient requires post-hospital: ... respiratory therapy ... oxygen ..."

Review of Patient 1's discharge medical record failed to show documented evidence that a discharge order was placed for supplemental oxygen.

Review of a document titled, "Nurses Notes," dated 02/19/25 at 6:42 PM, showed, " ... [the Hospital] used our [non-medical taxi service that utilizes independent drivers that use their personal vehicles] account and set up a ride to [Hospital 2] ..."

Dunring an interview on 03/05/25 at 2:55 PM, Staff K, Registered Nurse (RN), stated that Patient 1 was to be discharged home, but the patient had requested transportation service to take her to [Hospital 2]. Staff K stated that Patient 1 was receiving oxygen when she was wheeled down to the discharge exit and the oxygen was removed prior to Patient 1 leaving with the non-medical taxi service. The hospital did not provide oxygen or ensure that Patient 1 had access to oxygen during transport.

Review of a Hospital 2 document titled, "ED [Emergency Department] to Hosp [Hospital 2]-Admission," dated 02/19/25 at 7:05 PM, showed, " ...· Shortness of Breath ... Pt [Patient 1] states she was discharged in an [non-medical taxi service that utilizes independent drivers that use their personal vehicles] from [Above Named Hospital] and told to come to [Hospital 2] ED. Pt [Patient 1] states she is normally on [oxygen] 4LPM [liters per minute] via NC [nasal canula] for COPD and CHF [congestive heart failure]. Pt [Patient1] was discharged from [Above Named Hospital] without oxygen and oxygen saturation was 50 percent on arrival which was increased to 99 percent on her normal oxygen.) ..."

The hospital's failure to ensure that supplemental oxygen was provided during transport resulted in Patient 1 becoming hypoxic and required admission to Hospital 2 for further evaluation and stabilization treatment.