HospitalInspections.org

Based on review of medical records, facility documents and staff interviews, it was determined that the facility failed to provide nursing services that adhere to the accepted standards of care as evidenced by failing to ensure that the physician's order for oxygen was followed. This failure has the potential to affect all patients receiving services at the facility (see tag A-0395).

Cross reference: §482.23(b)(3) - A registered nurse must supervise and evaluate the nursing care for each patient.

Based on medical record review, facility documents and staff interviews, it was determined that the facility failed to assess the patient's care needs in accordance with accepted standards of care, as evidenced by failing to ensure that the physician's order for oxygen was followed in one (1) of ten (10) medical records reviewed (patient #1). This failure has the potential to affect all patients receiving services at the facility.

A review of the medical record for patient #1 revealed the patient arrived by Emergency Medical Services (EMS) on 01/05/25 to the Emergency Department (ED) with reported episodes of violent behavior and three (3) days of altered mental status. Patient #1 has a history of substance abuse, alcoholism, hyponatremia, gastroesophageal reflux disease (GERD) and bipolar disorder. The patient was admitted on 01/05/25 for altered mental status and drug overdose. It was determined that the patient was suffering from tachycardia and hypoxia. The patient was placed on oxygen and admitted to the hospital..

Review of document titled, "Discharge Documentation", dated 01/09/25, completed by staff #2 states "...Today, mental hygiene was held at the patient's bedside, which time is indicated the patient would be court ordered to inpatient psychiatric care. While [he/she] does require ongoing supplemental oxygen, qualification testing was completed, requiring 2 [two] to 3 [three] L/min [liters per minute] via nasal cannula. Patient will therefore be discharged to police custody with supplemental oxygen in place to be transported to the appropriate psychiatric care center..."

A review of a document titled, "Result Details, (Patient Status Rounding)", dated January 9, 2025, at 5:00 p.m., completed by staff #9 states "Police officer given discharge papers and scripts, IVx2 [Intravenous times two] removed with catheters intact. pt [Patient] dressed. Sent with [facility #39's] O2 [oxygen] tank per hospitalist on 3 [three] liters nasal cannula."

A review of a document titled, "Result Details" dated January 9, 2025, at 5:21 p.m., was completed by staff #9. The document states "Pt [Patient] up in wheelchair discharged off floor with oxygen and police officer."

A review of a document titled, "House Report", dated 01/10/25, was completed. The report rendered no evidence documenting that there were any issues with the patient transport. There was no mention of the police officer refusing to transport the patient with an oxygen cannister nor that the oxygen was brought back, and patient was transported without physician ordered oxygen."

A review of the nursing supervisors job description date unknown, was completed. The document states under "Summary", "The House Supervisor will coordinate total patient centered care, both meeting the physical, age-specific social, mental status, cultural and spiritual of the patients and ensuring optimal care and service in accordance with the physician orders... Responsibilities: Communicates changes to physician and staff..."

An interview was conducted on 03/31/25 at 12:50 p.m., with staff #6. Staff #6 stated, "Police officer called and said someone needs to come and get the oxygen. The patient was hitting the window and the mesh, and he wasn't going to allow another weapon in the car. Staff explained [patient] was on oxygen and needed it and he said I will not have another weapon in
the car. I did not ask the police to wait and I did not call the provider and tell them. I told the nurse, not sure which nurse."

An interview was conducted on 3/31/25, at 1:10 p.m. with staff #2. Staff #2 stated "I would want the nurse to contact provider. We thought the oxygen was brought back the next day. We could have made other arrangements for transportation, or we would have kept [him/her]. [He/She] didn't want the family or anyone to know anything about his care. [He/She] had stated it on numerous occasions that [he/she] didn't want family or MPOA [Medical
Power of Attorney] to know what was going on with them."

An interview was conducted on 4/2/25 at 8:00 a.m., with staff #11. Staff #11 stated "I concur that the nurse should have contacted provider and asked for guidance and if unavailable, you could contact administration on call. Nurses must follow physician's order. It's the whole makeup of our practice. We don't have a policy to address following the physician's order but it's standard practice."

An interview was conducted on 04/01/25, at 11:01 a.m. with staff #5. Staff #5 stated "I was not made aware that the patient had left without their oxygen. No, I wasn't notified that there was a problem or that the oxygen had been returned. This is the first time hearing of it."

Based on medical record review, policies and procedures review, documentation review and staff interviews, the facility failed to ensure that medical records were kept confidential and not released to an unauthorized individual for two (2) of ten (10) patients reviewed (Patient #1 and #2). The facility released the patient's medical records to the Medical Power of Attorney after the representation had been terminated due to death. This failure has the potential to affect all patients receiving services.

A review was conducted of patient #2's medical record. The patient arrived by Emergency Medical Services (EMS) on 03/04/25 and admitted for mild hypoxia. Patient #2 has a long history of documented substance abuse, alcoholism, hyponatremia, gastroesophageal reflux disease (GERD), and bipolar disorder. The patient was pronounced dead on 03/11/25 at 8:08 p.m..

A review of a document titled "Authorization for Release of Protected Health Information" A request for two (2) years of patient #1 and #2's medical records was signed by patient #1 and #2's sibling on 03/13/25 at 2:17 p.m. and was given to the sibling by employee #17 on 03/13/25 no time noted.

It should be noted patient #1 and Patient #2 are the same patient.

A review of policy titled, "Release of Information Guidelines", last revised 12/24, states "Policy: It is the policy of [the facility] to preserve the confidentiality and security of Protected Health Information created, received, obtained, maintained, used or transmitted by [the facility], and to protect this information from unauthorized access or disclosure."

A review of policy titled, "Patient Rights and Responsibilities", last revised 03/25, states "All patients seeking treatment or care at [the facility], ("HOSPITAL or HOSPITALS") have rights which are described below. Information on these rights is available to all patients upon request...A patient has the right to every consideration of his or her privacy, safety, and security concerning his or her own medical care program."

An interview was conducted on 04/01/25, at 9:30 a.m. with staff #11. Staff #11 stated "I concur we should have gotten estate documentation. We did release the medical records based on the MPOA (Medical Power of Attorney) paperwork. We did not get the estate documentation."