HospitalInspections.org

Based on interview and record review it was determined the facility failed to ensure one (1) of eleven (11) sampled patients were educated regarding instructions for post-hospital care. Patient #2 was discharged after outpatient surgery without instructions for management of the surgical wound at home.

The findings include:

Review of the facility's policy titled "Patient Admission, Transfer and Discharge for Short Stay Patients", revised 06/2011, revealed all patients were to be provided a discharge instruction sheet.

Review of the clinical record revealed Patient #2 was admitted to the facility, on 08/24/12, for an outpatient surgery, including the excision and biopsy of a soft tissue mass on the right lower extremity. Review of the Post-Operative Progress Notes, signed by the physician on 08/24/12, revealed the surgical procedures performed included "Excision and biopsy right leg mass".

Review of the Nurse's Note, dated 08/24/12 at 12:05 PM, revealed a Coverderm dressing was in place to the right lower leg. Continued review revealed the patient was discharged from the facility at 12:20 PM.

Review of the Wound Care section of the Outpatient Surgery Discharge Instructions, dated 08/24/12, revealed no reference to the dressing on the right lower leg. Continued review revealed no documented evidence the patient was instructed on how, or when, to change the dressing.

Interview with the Manager of Perioperative Services, on 03/28/13 at 11:50 AM, revealed how to care for any surgical wound should be included on the discharge instructions form.