HospitalInspections.org

Based on record review and staff interview it has been determined that the hospital failed to adhere to their policy, to ensure that the Continuity of Care form, included instructions and information regarding the patient's wound measurements and ongoing dressings/treatments for 1 of 4 patients reviewed, Patient ID #1.

Findings are as follows:

Review of the hospital policy titled "Skin Care Protocol: Prevention, Treatment and Use of Pressure Relief Devices" Revised 3/2023 states in part:

Documentation:
...6. Include documentation of wound care on the Continuity of Care Form along with wound measurement, treatment and teaching/supplies/equipment needed for discharge.

Review of Patient ID #1's medical record revealed a 47 year old, with a known history of chronic schizophrenia, and homelessness, who was emergency certified due to symptoms of delusional thinking and self-neglect resulting in a severe wound infection. The patient was transferred and admitted to Our Lady of Fatima's behavioral health unit on 5/6/2025 for ongoing treatment.

Upon the patients discharge on 5/14/2025, a Continuity of Care Form was given to the patient indicating that the patient needed to attend continued follow up appointments for wound care at the hospital's outpatient wound clinic. An appointment was scheduled for follow-up on 5/22/2025 at 10:30 AM.

The Continuity of Care Form included a note written by Registered Nurse, Staff A, that wound care supplies were given to the patient upon discharge, although the document did not include patient instructions on how he/she was to care for the wound.

During a surveyor interview with the patient's Registered Nurse, Staff A, on 6/3/2025 at 10:30 AM, he confirmed that he discharged the patient and provided the patient with a bag of dressing supplies. Staff A stated that he instructed the patient to do the dressing the same way that the wound care specialist had done it. Staff A acknowledged that he did not include any dressing instructions, or wound measurements on the patient's Continuity of Care Form per the hospital's policy.

During surveyor interview with the Wound Care Specialist, Staff B, on 6/3/2025 at 1:00PM, she revealed that she was aware that the patient was going to be discharged soon, however she was not contacted on the day of the patient's discharge to provide guidance about the patient's dressing change instructions. Staff B also acknowledged that the Continuity of Care Form did not provide the patient with dressing change instructions per the hospital's policy.