HospitalInspections.org

Based on policy review, medical record review and interview, the facility does not implement an accurate, complete discharge plans including instructions to meet the discharge needs for 3 of 11 patients (Patient #1, 26 and 27). Failure to provide complete documentation and instructions could lead to readmission or inadequate care.

Findings include:

Review of policy # CSC0098 " Guidelines for the Discharge of the Patient and the Discharge Plan " indicates registered nurse (RN) responsibilities include the completion of the Discharge Interdisciplinary Assessment and the individual the plan was reviewed with. The Discharge Plan and Plan of Care is to be reviewed for completeness.
Review on 11/10/16 of the medical record from 07/23/16 to 09/07/16 for Patient #1 revealed decubitus ulcers located sacrum, coccyx, left & right ischium with a long term jejunostomy tube and tracheostomy. Care Management/discharge planning notes dated between 07/24/16 and 09/07/16 revealed no documentation of discussion between the facility and group home related to decubitus ulcer, jejunostomy or tracheostomy care. The 09/06/16 physician transfer summary indicates " Santyl " as wound treatment but does not include wound care instructions. The transition of care/nursing discharge summary dated 09/06/16 does not indicate the presence of an ischium/coccyx decubitus and/or wound care instructions. In addition, no care directions are listed related to jejunostomy or tracheostomy care. Patient #1 returned to the hospital on 09/07/16.
Review on 11/10/16 of the medical record from 10/08/16 to 11/07/16 for Patient #26 revealed a stage 2 decubitus located on his right coccyx and a right trans metatarsal amputation with debrided ulcer. He was discharged to a nursing home on 11/07/16. The transition of care/nursing discharge summary dated 11/04/16 was not updated prior to discharge and does not include wound location and/or wound care instructions related to the right coccyx decubitus and/or the right trans metatarsal amputation ulcer. The physician discharge summary dated 11/07/16 indicates Patient #1 had a right trans metatarsal amputation ulcer but does not include wound care instructions. The stage 2 decubitus on right coccyx is not listed.
Review on 11/10/16 of the medical record from 10/09/16 to 11/08/16 for Patient # 27 revealed an abscess of right chest wall and right antecubital region. Patient #27 was discharged on 11/08/16 with a wound vacuum to the right chest. The transition of care/nursing discharge summary does not provide information related to the use/care of the wound vacuum, specifically if it should become loose or disconnected.
Interview on 11/10/16 at 11:00 AM with Staff # 1 and Staff # 4 verified these findings.