HospitalInspections.org

Based on document review and interview the hospital staff failed to ensure that a patient received completed discharge instructions, and a safe discharge (see tag 813), for 1 of 10 MRs (Medical Record) reviewed. (Patient # 6).


The cumulative effect of this systemic problem resulted in the facility's inability to ensure that safe Discharge Planning was promoted.

Based on document review and interview the nurse failed to ensure complete supervision and nursing care provided to 1 of 10 MRs (Medical Record) reviewed. (Patient # 6).

Findings include:

1. Facility policy titled, "Care Management Plan for Discharge Planning", policy number: none listed, indicated on page 1, under I. Identification of patients in need of discharge planning, A., All patients are screened by nursing services for potential discharge needs; and on page 2, under III. Discharge Plan, B. The Care Manager will develop discharge plan with input from the patient and/or caregiver, D. The Care Manager will reassess the patient's discharge plan and any factors that may impact the patient's continuing care needs. Last revised 12/2024.

2. Facility policy titled, "Inpatient Acute Nursing Guidelines of Patient Care", policy number: none listed, indicated on page 7, under Interventions: Global Interventions; The nurse will perform interventions to meet the individualized needs and problems of the patient, and on page 10, under Respiratory Care Management: Maintaining oxygen delivery system: reassessment after every change to oxygen; oxygen saturation will be monitored. Last revised/approved 6/2025.

3. Review of MR for patient # 6, reflected the following:
(a). Patient admitted on 4/27/2025 to 3rd floor (Progressive unit) after seen, evaluated, treated in the ED/ER (Emergency Department/Emergency Room) on evening/night of 4/26/2025 for complaints of: weakness, SOB (shortness of breath) and cough. Patient had been brought to AH # 40's (Acute Care Hospital) - (ED/ER by ambulance/EMS (emergency medical services).
Patient was discharged on 5/1/2025 to home (to address provided by patient) via transport service, with discharge instructions.
(b). H&P (History & Physical) on 4/27/2025, by MD # 30 (Doctor of Medicine-MD/Hospitalist) reflected patient does have a history of chronic daily/mild dementia, but after speaking to contact, it was found that patient was brought in due to being a little more altered than usual. Patient history also included: COPD (Chronic obstructive pulmonary disease). Patient on 4 L (liters) of oxygen at home and albuterol as needed.
(c). Nurse note on 4/28/2025 at 10:30 pm, reflected O2 (oxygen) at 3 L, sat (saturation) = 99%.
(d). RT (Respiratory) flowsheets (during patient's hospital stay) reflected O2 nasal cannula use: 3 L to 1 L; O2 sats = 95% to 98%.
(e). Nurse flowsheet on 5/1/2025 morning, for Respiratory: reflected patient denies shortness of breath, 2 L nasal cannula. Respirations: regular and unlabored. O2 sat = 100%.
(f). CM (Case Management) note on 5/1/2025 at 4:29 pm, by S # 10 (Case Management) reflected patient discharged home with no needs. CM arranged for transport service, address listed in note.
(g). The MR lacked documentation - entries by nursing staff in regards to the following:
1. Any belongings that the patient had arrived with on admission (i.e. shoes).
2. Any type of footwear patient was dressed in at time of discharge.
3. For an assessment of respiratory status prior to discharge: respiration rate, oxygen saturation; with patient on room air, as patient was discharged with no supplemental oxygen for transport to home.
3. That patient was sent via transport to a different address than her/his own for discharge.
4. If the address was checked and verified as having been correct for the patient.

4. In interview on 6/18/2025 at approximately 1:50 pm, with S # 12 (Case Management), confirmed that they don't see what belongings patient is leaving with; not part of patient dressed - shoes or no shoes for discharge; prepare for transport service arrival. That is nursing's responsibilities.

5. In interview on 6/18/2025 at approximately 1:40 pm and at approximately 2:28 pm, with S # 10 (Case Management), confirmed the following:
a. Patient # 6 did not ask for anyone to be called; family - emergency contact or FM # 1 (family member). Patient able to make a call; believe patient could have made a call.
b. Address given by patient # 6. Did not double check face sheet, went with what patient said. There are times when facesheets are wrong. Did not realize patient address on facesheet was different than one patient wanted to go to.
Address on facesheet could be from a previous stay.

6. In interview on 6/18/2025 at approximately 2:25 pm, with S # 11 (Case Management), confirmed - No recollection of what belongings patient # 6 had with her/him.

7. In interview on 7/9/2025 at approximately 2:37 pm, with FR # 20 (Friend) the following was indicated:
a. When the patient (Patient # 6) arrived at FR # 20's house, after discharge from AH # 40, the patient was barefoot.
b. The patient (Patient # 6) was discharged to FR # 20's house (Patient's previous address). Patient arrived via a transport service.
c. The patient (Patient # 6) has oxygen at home. Has used oxygen for the last 16 to 18 years.

8. It was determined that Patient # 6's arrival at FR # 20's house was not planned, and was discharged without oxygen or a respiratory assessment being completed prior to hospital discharge.

Based on document review and interview, the hospital staff failed to ensure that a patient received completed discharge instructions, and a safe discharge, for 1 of 10 MRs (Medical Record) reviewed. (Patient # 6).

Findings include:

1. Policy titled, "Inpatient Acute Nursing Guidelines of Patient Care", policy number: none listed, indicated on page 16, under Discharge: discharge assessment will include, understanding of discharge instruction from nurse, including patient teaching. Last revised/approved 6/2025.

2. Policy titled, "Care Management Plan for Discharge Planning", policy number: none listed, indicated on page 2, under III. Discharge Plan, B. The Care Manager will develop discharge plan with input from the patient and/or caregiver, D. The Care Manager will reassess the patient's discharge plan and any factors that may impact the patient's continuing care needs. Last revised 12/2024.

3. Review of MR for patient # 6, reflected the following:
(a). Patient admitted on 4/27/2025 to 3rd floor (Progressive unit) after seen, evaluated, treated in the ED/ER (Emergency Department/Emergency Room) on evening/night of 4/26/2025 for complaints of: weakness, SOB (shortness of breath) and cough.
(b). H&P (History & Physical) on 4/27/2025, by MD # 30 (Doctor of Medicine-MD/Hospitalist) reflected patient does have a history of chronic daily/mild dementia, but after speaking to contact, it was found that patient was brought in due to being a little more altered than usual.
(c). Patient was discharged on 5/1/2025 to an address (address provided by patient), that was not the noted home address for the patient as listed on the patient's facesheet; via transport service.
(d). MR documentation lacked completed/received - signed discharge instructions by the patient.
(e). The MR lacked documentation - entries by nursing staff in regards to the following:
1. That patient was sent via transport to a different address than her/his own for discharge.
2. If the address was checked and verified as having been correct for the patient.

4. In interview on 6/18/2025 at approximately 1:40 pm and at approximately 2:28 pm, with S # 10 (Case Management), confirmed the following:
a. Patient # 6 did not ask for anyone to be called; family - emergency contact or FM # 1 (family member). Patient able to make a call; believe patient could have made a call.
b. Address given by patient # 6. Did not double check face sheet, went with what patient said. There are times when facesheets are wrong. Did not realize patient address on facesheet was different than one patient wanted to go to.
Address on facesheet could be from a previous stay.

5. In interview on 7/9/2025 at approximately 2:37 pm, with FR # 20 (Friend), the following was indicated:
a. When the patient (Patient # 6) arrived at FR # 20's house, after discharge from AH # 40, the patient was barefoot.
b. Patient arrived via a transport service.

6. It was determined that the patient (Patient # 6) did not arrive at her/his residence.