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Based on medical record review, staff interview, and review of facility policies, the facility failed to ensure patients had a comprehensive plan of care at discharge. This affected two (#6 and #3) patients of three patients reviewed for discharge with wounds and an implantable device. The facility census was 59.

Findings include:

1. Review of the medical record for Patient #6 revealed an admission date and time of 07/08/24 at 7:41 A.M. Patient #6 was an elective admission for cardiology services to place a cardiac pacemaker due to Patient #6 suffering from sinus pauses. Diagnoses included bradycardia and vasovagal and deglutition syncope. Patient #6 had a history of type 2 diabetes mellitus with long term use of insulin, hypertension, obstructive sleep apnea, morbid obesity, gastroesophageal reflux disease, hyperlipidemia, and vitamin D deficiency.

Review of the history and physical completed on 07/08/24, timed 7:41 A.M., revealed Patient #6 had a loop recorder implanted 06/19/24 with near syncopal episodes noted, mostly with swallowing. Two of the episodes were associated with bradycardia with pauses in the range of five seconds. Physical examination was unremarkable. The plan to proceed, agreed upon by the patient and the patient's wife, was to have an implantation of dual chamber pacemaker placed.

Review of the brief postoperative note dated 07/08/24 and timed 3:11 P.M. completed by Cardiologist D revealed , Patient #6 experienced no complications with all lead impedances and thresholds stable. The plan for Patient #6 was bedrest overnight, with chest x-ray and pacemaker evaluation in the then morning and then discharge to home if no complications. Follow up for staple removal on 07/16/24 at the cardiology office.

Review of the discharge note, dated 07/09/24 completed at 11:42 A.M., revealed Patient #6 had a permanent pacemaker placed with recommended follow ups in one week with primary care and in four weeks with cardiology.

Review of the discharge paperwork printed on 07/09/24 at 2:24 P.M. revealed Patient #6 received educational information on COVID, stroke, warning signs of a heart attack and the use of opioids. Patient #6 was scheduled for a wound check on 07/17/24 at 11:30 A.M. and a device check on 07/20/24 at 9:30 A.M. There were no instructions for wound care or any information on the pacemaker.

Interview on 08/13/24 at 10:30 A.M. with Registered Nurse (RN) K verified Patient #6 had not received discharge instructions for wound care or any information on the pacemaker.

2. Review of the medical record for Patient #3 revealed an elective admission date of 07/29/24 for an implantable cardioverter-defibrillator replacement. Patient #3 diagnoses included legal blindness, coronary artery disease, with a history of coronary bypass surgery, congestive heart failure, sleep apnea, hyperlipidemia, type 2 diabetes mellitus, and hypertension.

Patient #3 was care planned on 07/29/24 for discharge planning with a goal to discharge home with appropriate resources.

Review of the social Case Management Assessment and Initial Evaluation dated 07/29/24 and timed 3:35 P.M. revealed Patient #3 lived at home with spouse, planned to return to home, and was independent with activities of daily living.

Review of the procedure note dated 07/31/24 and timed 5:14 P.M. revealed Patient #3 had a new pulse generator placed in the left upper chest on 07/29/24 without complication due to defibrillator battery depletion.

Review of the Occupational Therapy note dated 07/31/24 revealed Patient #3 would benefit from continued therapy at discharge with a plan for Occupational Therapy two to three times a week for self-care needs, home management training and safety education due to position restrictions as result of the pacemaker.

Review of the discharge paperwork printed on 07/31/24 at 12:22 P.M. revealed Patient #3 received discharge education on stroke, heart attack, heart failure, and COVID. Patient #3 was provided continuation of care documents that included medications, follow up appointments and home health services that had been arranged. There were no instructions for wound care or any information on the pacemaker.

Interview on 08/12/24 at 1:30 P.M. with RN K verified Patient #3 had not received discharge instructions for wound care or any information on the implanted device, further stating the information was sent to the home health agency.

Interview on 08/13/24 at 2:00 P.M. with Nurse Manager S verified patients who have received implantable devices have inconsistent discharge instructions, furthering verifying all patients should receive information on wound management and device information.

Review of the facility policy titled "Individual Rights and Responsibilities," dated 05/05/23, stated all healthcare providers have the responsibility to assure that patients receive care and consideration in accordance with the mission and values of the organization. Patients have the right to be informed, be involved in decision making, be provided with furnishings and equipment that are safe and fit their needs, and have the right to receive information regarding care, proposed treatments or procedures and or healthcare services.

Review of the facility policy titled "Discharge Planning," dated 03/25/24, revealed discharge is a multidisciplinary process by which healthcare professionals collaborate with the patient and caregiver to identify what the patient needs for a smooth, safe transition to the next level of care. The discharge plan will be made after identifying discharge planning needs so that appropriate arrangements for post-hospital care are made timely and to avoid unnecessary delays. Documentation of the communication about discharge evaluation must be included in the medical record.

Review of the facility policy titled "Nursing Documentation Requirements," dated 05/27/24, stated discharge documentation requirement includes signs and symptoms to report with contact information for reporting, any activity restrictions, post discharge education including treatment prescribed.