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Based on record review and interview, the facility failed to document in the discharge plan, given to the patient and care giver, the daily dressing changes for the head mass for for Patient #1.


Findings:


Patient (#1).

Record review of admission records for Patient (# 18) revealed he was admitted to the facility on 8/29/18 with diagnosis of a progressive crainial mass which required antibiotics and daily dressing changes.

Record review of the discharge planning notes dated 9/7/18 revealed the patient was discharged home with an Adult Protective Services approved Care Giver.

Further review of the Discharge Summary revealed there was no mention of the daily dressing changes.


Record review of the Nurses note, dated 9/7/18 at 17:43 states....Patient discharged home, using teach back regarding new meds, new appointments to follow up appointments, dressing changes, signs and symptoms to watch for and when to call 911.


Interview on 10/24/19, at approximatley 2:30 p.m. with the facility Licensed Masters Social Worker (LMSW), revealed she was trying to get the patient discharged in a Nursing Home facility, but the Adult Protective Services care giver refused and stated she could care for the patient herself. The caregiver was instructed on how to care for the patient's daily dressings to the head and was given the supplies. The nurse just forgot to document on the discharge instructions the daily dressing changes.


Interview on 10/24/18, at approximately 4:00 p.m. with the facility Chief Nursing Officer, confirmed the above findings and revealed it was the Nurse's responsibility to document the daily dressing changes to the discharge instructions.