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SAINT JOSEPH HOSPITAL 1375 EAST 19TH AVENUE DENVER, CO 80218 Aug. 19, 2015
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on observations, interviews and document review, the facility failed to ensure the initial implementation of the patient's discharge plan in 1 of 10 patient records reviewed (Patient #3).

This failure created the potential for negative patient outcomes when the patient was discharged .

FINDINGS

POLICY

According to the policy Discharge Planning and Process, discharge planning is a multidisciplinary responsibility and begins at the time of admission. Care Management staff coordinate continuing care needs and make available appropriate community resources and appropriate facilities as needed. In addition, Registered Dietician (DR), Physical Therapist/Occupational Therapist (PT/OT), Respiratory Therapy (RT), Pharmacy, and Care Management assist with arrangements for equipment and supplies as appropriate.

According to the policy Discharge With Oxygen - Patient Instructions, the Respiratory Therapy Department and Pulmonary Lab will complete home oxygen arrangements as prescribed by the physician.

1. The facility failed to ensure initial implementation of the patient discharge plan which included referral for essential durable medical equipment.

a) Review of Patient #3's record showed a physician order, dated 05/15/15, at 9:38 a.m., for home oxygen setup with oxygen concentrator, and portable stationary oxygen gas tanks, via nasal cannula at 3 liters, to be used during exertion.

A review of the physician discharge summary, dated 05/16/15 at 10:11 p.m., revealed a patient room air oxygen saturation of 81% during ambulation, requiring 3 liters of home oxygen. A review of the patient discharge instructions/After Visit Summary noted the need for 3 liters of oxygen with activity and provided the name of a home care company.

Review of respiratory therapy documentation, dated 05/15/15 at 8:46 a.m. (day of discharge), revealed a home oxygen evaluation but did not include documentation that home oxygen was arranged and available for use upon discharge for Patient #3.

b) In an interview with Respiratory Therapist (RT) #12, on 08/18/15 at 3:52 p.m., RT #12 described the process for procuring home oxygen for a discharging patient when a physician order for oxygen was present. RT #12 stated the process included assessing the patient on room air Oximetry at rest and with exercise and titration of oxygen as needed; discussing home oxygen needs with the patient and family, determining which oxygen company and type of oxygen system would be used; contacting the home oxygen company with physician order and patient information. The home oxygen company therapist would provide a portable unit at the hospital for the patient to take home and coordinate a stationary unit delivery. RT #12 stated s/he contacted the home oxygen company the afternoon of 08/17/15, and no paperwork surrounding the home oxygen set up for Patient #3 was found.

c) An interview with RT #14, on 08/19/15 at 8:31 a.m., revealed s/he performed the evaluation for supplemental home oxygen for Patient #3, and the patient required oxygen during ambulation. S/he stated the home oxygen provider accepted Patient #3, but would not begin the oxygen setup process without a known patient address. RT #14 stated s/he did not notify a supervisor or the case manager regarding the inability of the home oxygen provider to set up oxygen equipment. According to RT #14, at the end of the work shift, s/he passed the home oxygen setup paperwork to the oncoming respiratory therapist. S/he was unable to remember which respiratory therapist the paperwork was passed to. When asked if s/he notified the ordering physician about the possible inability to follow the physician order for home oxygen setup, s/he stated, "no". RT #14 was unable to verify home oxygen had been set-up for Patient #3.

d) On 08/19/15 at 10:55 a.m., a phone interview with Registered Nurse (RN) #6 was conducted. Interview revealed the discharge of Patient #3 was completed by RN #6 and occurred "over shift change, just after the beginning of my shift". RN #6 stated s/he was unaware Patient #3 required home oxygen upon discharge.

e) On 08/19/15 at 12:45 p.m., in an interview with the Chief Nursing Officer (CNO) #1, s/he revealed the expectation was for all physician orders to be followed and physician contact was to occur if staff were unable to complete an order for any reason. CNO #1 stated patients had the right to refuse, but staff were required to document refusal when a physician order was not followed.

f) An interview with Medical Doctor (MD) #15, on 08/19/15 at 2:59 p.m. revealed s/he did not know if Patient #3 was discharged from the hospital with home oxygen, and s/he had not received notification regarding the inability to set Patient #3 up with home oxygen. MD #15 stated s/he expected the hospital staff to notify him/her if they were unable to discharge the patient with home oxygen as ordered.