HospitalInspections.org

Based on interview and record review, the facility failed to provide a safe discharge plan for 1 (P-1) of 20 patients reviewed for Discharge Planning, resulting in poor health outcomes and subsequent death. Findings include:

See tag 0807 - Failure to identify and provide discharge needs.

Based on interview and record review, the facility failed to follow it's policy regarding wound assessment and documentation, for 1 (P-1) of 10 patients reviewed, resulting in the increased potential for missed infections and treatment delays, for all patients receiving wound care. Finding include:

Review of "History of Present Illness (HPI)" dated 06/18/25 at 0922 revealed, "(P-1) is a 67-year-old male, past medical history of heart failure with low ejection fraction...Reviewed discharge summary from February 20, 2025 when patient presented with very similar presentation required (diuretic; removes excess fluid) drip for volume (fluid in body) control."

Review of "Flowsheets" dated 06/18/25 at 1652 revealed that P-1 had a leg wound assessed and documented as "scab, cracked."

Review of P-1's medical record on 08/20/25 at 0930 with Nurse Executive (Staff D) revealed that the wound was located on P-1's lower right leg and was documented as "Venous Ulcer Pretibial Proximal Right." "Dressing Status" listed "wound observed, dressing rescued." Site assessment states "Dry, red". Peri-wound assessment lists "Black;intact." Drainage as "none" and Wound Care lists "Enzymatic debridement; Open to air."
Further review of the medical record demonstrated documentation that P-1's leg wound was assessed and treated daily, however, no wound treatment orders or wound medication orders were located in the medical record.

During chart review on 08/20/25 at 0940, Nurse Executive Staff D was queried for the size, depth, color and staging of P-1's leg wound. Staff D stated that the wound dimensions and staging were not documented in the medical record.

During interview with Nurse Executive Staff D on 08/20/25 at approximately 1000, Staff D was questioned if she expected wounds to be measured when assessed? Staff D stated, "No, if its a venous ulcer." Staff D was next questioned "Why not?" Staff D stated, "It's not a pressure injury." Staff D was next questioned if a Wound Ostomy Nurse (WOCN) consult was ordered for P-1. Staff D searched the medical record and replied, "They did not consult the wound nurse, I could not find one (order)." Staff D was next questioned if she expects nurses to assess and document non-pressure injury wounds. Staff D stated, "I expect them to describe it, and if its big enough, to measure it. I would expect some description."

Review of facility Wound Care policy titled "Pressure Injury Prevention," #18160590, effective 05/25, revealed "If a pressure injury or any other alterations to intact skin are present, clearly describe and document the alterations including: Appearance of the wound bed, drainage, surrounding skin, and odor. 1. Measurements in centimeters of length, width, and depth of pressure injury or other skin alteration (see Attachment 5 for more detailed wound assessment and documentation terminology). 2. STAGE of pressure injury, used only if wound is a pressure injury 3. Indicate if Present On Admission (POA). 4. Notify the provider of findings."

Based on interview and record review, the facility failed to provide a safe discharge plan for 1 (P-1) of 20 patients reviewed for Discharge Planning, resulting in poor health outcomes and subsequent death. Findings include:

Review of the medical record revealed that P-1 had two admissions to the facility of concern in 2025, (1.) 06/18/25 through 06/27/25 (nine days) and (2.) 07/15/25 through 07/16/25 (19 hours).

Review of "History of Present Illness (HPI)" dated 06/18/25 (first admission) at 0922 revealed, "(P-1) is a 67-year-old male past medical history of heart failure with low ejection fraction of 14% with severe left ventricular (LV) hypokinesis (poor wall motion) status post AICD (automated internal cardiac defibrillator), EtOH (alcoholic) cirrhosis, type 2 diabetes, prior LV thrombus (blood clot) on Xarelto (blood thinner), atrial fibrillation presents for evaluation of lower extremity edema and shortness of breath...Reviewed discharge summary from February 20, 2025 when patient presented with very similar presentation required Bumex (diuretic; removes water) drip for volume (of fluid in body) control. Following this he was discharged home on GDMT (goal directed medical therapy) however also has had issues with hypotension..

Review of HPI (2nd admission), dated 07/15/25 at 1535 revealed (P-1) is a 67-year-old male with past medical history... brought into the resuscitation room via ambulance after being found down... I was able to get a hold of the patient's brother (redacted) who confirmed that the patient would want CPR (cardio-pulmonary resuscitation), intubation, and all advanced life-saving means. He also reports that over the past week, the patient has been doing poorly. States that he has noticed that his brother has had increased leg swelling and belly swelling." P-1 was admitted to the facility with Sepsis (life-threatening infection) on 07/15/25 and expired the following morning.

Review of "Consults" dated 06/23/25 at 1556 revealed that P-1 was evaluated by Palliative medicine for decision making capacity, stating, "Patient not able to verbalize disease course and treatment plan; (patient wearing winter jacket in 90-degree heat.)" Psychiatric evaluation revealed "grossly oriented to place and person, not to context, unclear of time orientation." Judgement is impaired, as evidenced by general medical problems and needs OR ongoing monitoring and/or treatment of medical needs, refusal to take medication as prescribed (refusal of general care)."

Review of P-1's medical record on 08/20/25 at 0930 with Nurse Executive (Staff D) revealed that a wound was located on P-1's lower right leg and was documented as "Venous Ulcer Pretibial Proximal Right." "Dressing Status" listed "wound observed, dressing resecured." Site assessment states "Dry, red". Peri-wound assessment lists "Black; intact." Drainage is 'none' and Wound Care lists "Enzymatic debridement; Open to air." Staff D was queried for the size, depth, color and staging of the wound. Staff D stated that the wound dimensions and staging were not documented in the medical records. Staff D was next requested to review P-1's 'After Visit Summary (AVS; Discharge Instructions) for wound care instructions. Staff D stated that no wound instructions were present. Staff D was next questioned if P-1's AVS should include wound care instructions? Staff D stated, "I don't know." Staff D also reviewed the "Problem List" on the AVS and confirmed that 'wound' was not listed as a problem P-1 encountered during his visit.

During interview with Case Manager (CM) (Staff N) on 08/19/25 at 1130, Staff N was questioned how she identifies patient needs upon discharge. She reviews needs upon discharge, such as equipment, home care and durable medical equipment. Staff N stated, "He was once again ambulating, with a cane and walker. I talked to the manager of his NSO (Neighborhood Service Organization; home for chronically homeless) and confirmed with him that P-1 was to be discharged back to the home. They didn't express any concerns." Staff N was next questioned what medical needs she identified? Staff N stated, "He had no medical needs." Staff N was questioned if P-1's leg wound was discussed in morning rounds with physicians? Staff N stated, "There was no talk of wounds." Staff N was next questioned if she reviews patient records for wounds or decision-making capacity? Staff N stated, "There were no dressings or medical needs. He has capacity for taking medications, but not for complex decisions." Staff N was next questioned if she was in contact with Adult Protective Services (APS) regarding P-1. Staff N stated that the medical team called APS to express concerns about P-1's ability to self-care. Staff N was questioned if that was usual for the medical team to call APS? Staff N stated, "Oh yea, all the time. If APS wants to take the case, they follow-up. They do a safety evaluation of the home. APS was to assess and take over." Staff N was questioned if she attempted to notify family members that P-1 was being discharged? Staff N stated, "We attempted to contact the brother and friend (listed as emergency contacts) to no avail, throughout his admission. Thats why the manager contacted APS."

Review of "Progress Notes," dated 06/27/25 at 1527 revealed that APS was contacted three hours prior to P-1's discharge (1815), "Received a call from APS (adult protective services) regarding patient care. APS states someone will be out to evaluate patient within the next 72 hours."

An interview was conducted with P-1's Pulmonologist (lung doctor) (Staff GG) on 08/20/25 at 1212. Staff GG was questioned about P-1's mental capacity. Staff GG stated that P-1 was "Alert and Oriented x3, but didn't appreciate his medical needs, such as environmental safety and the need to be compliant with medications. Staff GG stated that P-1's leg wound "Did not appear infected or worrisome, if his CHF (congestive heart failure) resolved, the wound would heal." Staff GG was questioned how the wound appeared? Staff GG stated, "It was not infected based on exam, not red, no cellulitis or draining, no leukocytosis (high white blood cell count)." Staff GG was questioned if P-1 was on antibiotics? Staff GG stated, "No antibiotics, Santyl (debridement cream) is fine." Staff GG was next questioned if P-1's wound resolved prior to discharge? Staff GG quickly reviewed the medical record and replied, "The wound did not resolve, he refused assessment of the wound on 06/27/25 at 0817." Staff GG was questioned if P-1 would need to continue the wound care regimen of Santyl and dressing changes after discharge? Staff GG replied, "Yes and No. We felt the wound would heal with meds (taken for CHF) and dressing changes." Staff GG was questioned if P-1's wound had a dressing when he was discharged? Staff GG replied, "Yes." Staff GG was questioned when P-1's dressing would next need to be changed? Staff GG stated, "That would be based on the assessment of Home Care nurses." Staff GG was questioned what P-1 needed home care nurses to do for him? Staff GG reviewed the medical record and stated, "He needs his medications administered daily and his dressings changed. He needed Home Care."

Review of "Orders," failed to demonstrate any wound care orders ordered for P-1's wound treatment.

Review of "Discharge Summary" dated 06/27/25 at 1556 revealed that P-1 was discharged to home or self-care, with two ambulatory referrals to Cardiac Rehabilitation clinic and Hepatology (Liver) service. "Follow-up" is listed as "No follow-up provider specified." "Future Appointments" and "Home Health Future Appointments" was left blank.