HospitalInspections.org

Based on review of medical record #1, staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure that discharge instructions for wound care needs, are provided.

Findings include:

Reference: Facility policy titled, "Discharge Planning" dated 7/20 states, " ...Transfer of Information to Other Hospitals/Providers ... the patient's current course of illness and treatment ... Pertinent information concerning the identification of the patient's post hospital needs will be forwarded as part of the patient's medical record ... Necessary medical information to be provided ... the outcome of hospital treatment or follow-up care needs ... Patient's condition at discharge ... ."

On 03/20/23, a review of the medical record of Patient #1 (P1) revealed that P1 arrived in the Emergency Department (ED) on 01/13/23 at 8:38 AM with a chief complaint of altered mental status. P1 was admitted at 9:46 PM and discharged on 01/18/23 at 7:15 PM. The ED Provider note, dated/timed 01/13/23 at 4:23 PM, on the section labeled "HPI [history of present illness]" states, "... Further hx [history] is obtained by group home transfer sheet and EMS [emergency medical services] as patient is unresponsive upon arrival. EMS ... noted multiple wounds throughout the body."

The "Physical Exam" section of the ED provider note states, "... Skin: Multiple blackened wounds on the left. Blackened wound on the plantar surface overlying the first distal left first metatarsal. There are sacral wounds present."

A wound care evaluation completed on 01/16/23 at 11:00 AM by an Advanced Nurse Practitioner noted ulcers on the following areas: "... Sacrum ... Right ear ... Left great toe ... left heel ... Left outer heel ... Right foot outer aspect ... Scrotum ... MASD [moisture associated skin damage] to skin near anus-red ... ." P1's medical record revealed that his/her wounds were assessed, documented, and medications were ordered to treat his/her wounds.

Review of the discharge summary revealed there was no evidence of discharge instructions that addressed follow-up care for P1's wounds. A review of the Universal Transfer form completed when P1 was transferred back to his/her group home, did not identify P1's wounds in the space provided for "skin conditions." During an interview on 03/20/23 at 12:12 PM, Staff #4 (Vice President, Chief Nursing Officer) and Staff #5 (Assistant Nurse Manager) confirmed that there was no evidence of discharge instructions or documentation on the Universal Transfer form or in the discharge summary that addressed P1's post-discharge wound care needs.