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Based on interviews and document review, the facility failed to provide patient specific discharge instructions for post-hospital care in 2 of 2 patients with a history of Intravenous Drug Use (IVDU) (Patients #2 and #3).

This failure created the potential for increased infection risk and readmission.


FINDINGS

POLICY

According to the policy, Patient Discharge to Home or to Facility for Less Acute Care, assure patient has received appropriate teaching for post-hospital self-care and follow up care.

According to the policy, Transfer/Discharge Documentation, when a patient is discharged from the hospital, the registered nurse documents referrals and/or consultations with resource persons during stay and evidence of patient/family comprehension of instructions.

According to the policy, Discharge planning, all patients shall receive education regarding self-care after discharge. This is considered a routine ongoing component of care.

According to the policy, Insertion, Maintenance and Care for Central Venous Catheter/ PICC TX, all patients receiving a central line will be given home care instructions at the time of catheter insertion or upon discharge. The patient care or the PICC line nurse will go over the PICC line discharge instructions when the patient is discharged home.

According to the policy, Patient/Family Education, as a standard of practice, all patients will receive patient education via Care Notes or an appropriate educational substitute for their relevant diagnosis, which will be reviewed with them. A copy of what was provided is maintained in the record.


REFERENCE

How to Care for Your Peripherally Inserted Central Catheter (PICC) Discharge Instructions include: when to contact a health care provider, when to seek care immediately, how to prevent a bloodstream infection, patient signature of instructions.

1. The facility failed to ensure Patient #2 was given instructions regarding post-hospitalization PICC care and wound care prior to discharge.

a) Review of Patient #2's medical record revealed s/he was admitted on 09/11/17. On 09/22/17 at 4:55 p.m., Physician Assistant (PA) #2 documented in the Discharge Summary, Patient #2 had a right axilla (armpit) abscess which required an I&D (a surgical procedure to release pus or pressure) and daily wound care. According to the discharge summary, Patient #2 had a history of IVDU. PA #2 also documented the patient required a PICC due to poor venous access. PA #2 documented the discharge plan for Patient #2 would include daily intravenous (IV) antibiotics at an outpatient infusion center and s/he would need to follow up at the outpatient wound clinic for daily dressing changes of the axilla wound.

On 09/22/17 at 9:43 a.m., Physician (MD) #3 documented in the Progress Notes that Patient #2 was to be discharged home with the PICC line and go to the outpatient infusion center daily for IV antibiotic therapy. MD #3 also documented the discharge plan was to include continued wound care.

b) A Review of Patient #2's medical record revealed an order by MD #4 for Physical Therapy (PT) to evaluate and treat the axilla wound. The PT Discharge Summary included wound care instructions for daily wound care to the axilla to include: cleanse the wound with sterile water, pack the wound with ¼ inch packing strip, and cover the wound with 2 layers of aquacel and finally mepilex.

c) On 01/04/18 at 8:11 a.m., an interview was conducted with Wound Ostomy Continence Nurse (WOCN) #7 who stated the facility's normal process for wound care discharge instructions were wound care recommendations were to be put into the electronic health record (EHR). The patient's nurse would print the instructions and give them to the patient at the time of discharge. WOCN #7 stated the Case Manager (CM) would arrange outpatient wound care at the wound clinic and send the wound care instructions to the clinic. WOCN #7 reviewed Patient #2's medical record and reported s/he did not see documentation from physical therapy that Patient #2 had received wound care education prior to discharge.

d) On 01/03/18 at 3:11 p.m., an interview with CM #1 was conducted. CM #1 stated the WOCN should have ordered outpatient wound care at a wound care clinic. This was in contrast to the WOCN's interview. S/he reported case management should have arranged outpatient antibiotic therapy and PICC line care at an infusion center.

CM #1 reviewed Patient #2's medical record which revealed CM #8 had documented the patient was not a candidate for outpatient IV antibiotic therapy due to a history of IVDU. S/he wrote the patient would be discharged with no home needs. This was in contrast to provider orders and documentation. CM #1 reported the patient did not need PICC line education at discharge because s/he would be seen at the outpatient infusion center and the center would have provided care instructions.

e) On 01/04/17 at 9:59 a.m., an interview with RN #9 was conducted. RN #9 stated education should have been given to the patient during discharge which would include how to monitor and manage wound care and PICC line care. Wound care instructions would be entered in the EHR by the WOCN and then printed and given to the patient. According to RN #9, all nurses had access to a printed PICC education sheet to give to patients at the time of discharge.

f) RN #10 documented a discharge nurses note on 09/22/17 at 7:36 p.m. RN #10 documented Patient #2 had an axilla wound which required daily dressing changes and a PICC line for outpatient antibiotic therapy. RN #10 also documented dressing changes could be performed at the outpatient infusion clinic.

Review of RN #10's documentation of discharge instructions revealed Patient #2 did not receive specific instructions on how to care for the PICC or wound at home. Discharge instructions read "keep wound clean and dry" and follow up with outpatient infusion clinic tomorrow.

CM #1 reported the infusion center only managed PICC dressing changes, and did not manage wound care dressing changes. CM #1 stated the patient would need to be seen at the wound care clinic for daily dressing changes or perform dressing changes at home independently. CM #1 further stated case management had not arranged any outpatient service for Patient #2.

g) Subsequently, on 09/25/17 at 1:41 a.m., MD #5 documented in the Emergency Provider Report that Patient #2 returned to the Emergency Department (ED) with an issue regarding wound care. Patient #2 stated the packing had fallen out of his/her axilla wound at an unknown time. MD #5 documented wound care was provided as well as discharge instructions.

Two days later, on 09/27/17 at 7:54 p.m., MD #6 documented in the Emergency Provider Report that Patient #2 returned a second time to the ED with a complaint the PICC line was bleeding, painful, and was coming out. MD #6 documented the PICC dressing was changed and discharge instructions were given to Patient #2.

2. The facility failed to ensure Patient #11 was given instructions regarding post-hospitalization peripheral IV care prior to discharge.

a) Review of Patient #11's medical record revealed MD #11 documented in the Emergency Provider Report the patient presented to the ED on 07/25/17 with multiple resolving abscesses in the right arm, as well as an abscess that had appeared on the left forearm that morning. MD #11 further stated Patient #11 had a known history of intravenous drug use (IVDU) and had admitted to injecting IV drugs on 07/25/17 prior to arrival to the ED. An I&D of the new abscess was performed by Physician Assistant (PA) #12 while Patient #11 was still in the ED. Patient #11 was then admitted as an inpatient for medical treatment and IV antibiotics with a diagnosis of cellulitis (a bacterial skin infection) and an abscess (a confined pocket of pus) of the left arm. The Clinical Documentation Record showed the patient had an IV placed in the left antecubital (area anterior to the elbow) area on 07/25/17 at 11:50 a.m.

On 7/26/17 at 6:17 p.m., PA #2 documented in the hospitalist progress note that Patient #11's cellulitis of the left arm was due to IVDU. S/he also documented the discharge plan would be for the patient to go to the outpatient infusion center for daily peripheral IV for antibiotics. It was also recorded the patient was not to have a PICC line placed due to history of IVDU.

A Review of Patient #11's medical record showed discharge planning documentation by CM #1 on 07/27/17 at 11:03 a.m. which showed the patient would require a peripheral IV to be placed daily for IV antibiotics at the outpatient infusion clinic.

Patient #11 was discharged from the facility on 07/27/17. However, there was no documentation in Patient #11's medical record stating the peripheral IV had been removed or how to manage a peripheral IV during his/her post hospital phase.

b) On 01/03/18 at 3:11 p.m., an interview was conducted with Case Manager (CM) #1 who reviewed Patient #11's medical record. CM #1 stated Patient #11's discharge plan was to go to the outpatient infusion center on a daily basis to receive a peripheral IV so s/he could be administered daily antibiotics. CM #1 stated there was no documentation that Patient #11's IV had been removed prior to discharge.

c) On 01/04/17 at 9:59 a.m., an interview with RN #9 was conducted. RN #9 stated the risk of being discharged home with a peripheral IV (PIV) would be the possibility of developing an infection or an access to inject drugs. RN #9 went on to state it was facility policy to document the removal of PIVs prior to discharging a patient. RN #9 further stated there was no way to know if the PIV was removed if there was no documentation of removal.

d) Record review revealed Patient #11 was readmitted to the facility on 08/22/17 for a right antecubital abscess.