HospitalInspections.org

Based on medical record review, staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure the patient's right to participate in their discharge plan.

Findings include:

Reference: Facility policy titled, "Discharge Planning and Transitions in Care" (effective 2022) states, "... The discharge plan will consider the medical, social, psychological, financial, emotional, and age-related needs of the patient."

Review of the medical record of Patient #1 (P1), on 6/29/23, revealed P1 had a stage 2 pressure ulcer on his/her left buttock.

Review of the "Physician Discharge Instructions," dated 3/25/23 at 12:30 PM, lacked evidence of documentation of P1's stage 2 pressure ulcer of the left buttock, a prescription for the topical ointment he/she was being treated with, nor did the instructions indicate where or when P1 needed to follow up for wound care for a his/her stage 2 pressure ulcer. The discharge instructions were signed by P1 on 3/25/2023 at 12:30 PM.

On 6/29/23 at 10:00 AM, Staff #1 (S1), Director of Quality Management, indicated the facility was aware that P1's discharge instructions did not contain patient education, required medications, or recommended follow up care instructions regarding his/her stage 2 pressure ulcer of the left buttock.