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Based on document review and interview, the facility failed to ensure that patient's discharge planning included all patient treatments at the time of discharge in 1 out of 10 (patient 3) medical records (MR) reviewed.

The cumulative effect resulted in the hospitals inability to ensure safe discharge planning.

Based on document review and interview, the facility failed to ensure that patient's discharge planning included all patient treatments at the time of discharge in 1 out of 10 (patient 3) medical records (MR) reviewed.

Findings include:

1. Review of policy titled, titled, "CORE: Discharge Planning", approved 06/2020, indicated the physician will document in the patient medical record the post-discharge plan of care; the case manager will document final preparation information including reassessment of medical condition; and if modifications for discharge are identified, document findings and changes in the progress notes.

2. Review of Patient 3's MR lacked documentation of discharge plan of patient's oxygen needs. Provider orders in the MR indicated staff to tritrate oxygen to maintain O2 saturations greater than 88% and attempt to wean. On 10/03/2023, MR indicated that patient had desaturations on room air, was placed back on O2 per nasal cannula, and that patient had need for O2 support to maintain documented O2 saturations above 88%. On 10/04/2023, MR indicated that patient remained on 2 liters of O2 prior to discharge. MR lacked documentation to discontinue O2 at discharge.

3. A1 (Director of Case Management), on 11/08/2023, at approximately 1:00 pm confirmed that home O2 was ordered on 10/2/2023 and the order was canceled. A1 confirmed that MR lacked documentation regarding reason for cancellation of the home O2 order.

4. A7 (Registered Respiratory Therapist and Respiratory Manager), on 11/08/2023, at approximately 1:30 pm, confirmed that the patient had been on O2 via nasal cannula on day of discharge.

5. A1, A2 (Director of Quality), and A3 (Chief Clinical Officer/Chief Operating Officer), on 11/08/2023, at approximately 1:40 pm, confirmed that there was no written order to discontinue O2 by the provider and the MR lacked documentation to determine if the patient's need for oxygen was addressed prior to discharge. A3 confirmed the patient was discharged not wearing oxygen.