Failure to Ensure Timely Provision of Oxygen at Discharge
Penalty
Summary
A deficiency occurred when a resident with multiple respiratory diagnoses, including acute respiratory failure with hypoxia, pneumonia, morbid obesity, and COPD, was discharged home without timely provision of necessary supplemental oxygen. The resident, who had intact cognition, was insistent on leaving the facility despite recommendations to remain for further care. Physician orders specified the need for oxygen therapy to maintain adequate oxygen saturation, and discharge planning included arrangements for home health services and supplemental oxygen. On the day of discharge, the resident was provided with a portable oxygen tank and discharge instructions, but the durable medical equipment (DME) supplier did not deliver the prescribed home oxygen as expected. The facility staff sent the oxygen prescription to the DME supplier, but there was confusion regarding the script, and the supplier did not confirm delivery or communicate any issues. The staff did not verify that the oxygen was delivered to the resident's home, and the resident was left without a continuous supply of oxygen for several days following discharge. The resident and her family attempted to resolve the issue by contacting the facility and the DME supplier, but were unsuccessful in obtaining the necessary equipment until a different supplier was contacted and delivered the oxygen. During this period, the resident did not have access to prescribed supplemental oxygen at home, despite the facility's documentation that arrangements had been made. The lack of timely coordination and confirmation of equipment delivery resulted in the resident being unprepared for a safe discharge.