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Based on medical record review and staff interview, the facility failed to ensure the discharge summary included provisions for follow up care for one of ten patients whose medical records reviewed (Patient #6).

Findings include:

Review of the medical record for Patient #6 was completed on 05/19/21. The patient was admitted on 04/27/21 via ambulance and discharged on 05/06/21. The reason for admission was fatigue and septic shock. Other diagnoses included bacterial skin infection of the leg, wound of sacral region, essential paraplegia, spina bifida, and COVID-19.

Review of a wound nurse consult on 04/28/21 revealed the patient had a large mass on right lower extremity that was evaluated by surgery. There was a blister that had come unroofed (where the skin is rubbed or cut off) at the assessment. The wound nurse recommended Adaptic (non-adhering dressing) and an ABD pad (dressing used to absorb discharge from a draining wound) to cover the area. The wound nurse would continue to follow.

Review of a wound nurse note on 04/29/21 at 12:54 PM revealed they responded to consult for "right lower extremity hemorrhagic bulla ruptured; pressure ulcer L (left) lower buttock." The patient was seen and examined yesterday on 4/28/21 for same, with recommendations/orders in place. No changes to the orders were made and nursing staff was made aware. The wound nurse would continue to up as planned.

Review of a Pulmonary and Critical Care daily progress note dated 04/29/21 revealed the physician confirmed with the family the right lower extremity mass had been present for years, evaluated previously for cosmetic removal though they were unaware of violaceous (violet) area. Large flesh colored mass proximal posterior right lower leg with violaceous bulla (fluid filled blisters) and associated warmth; ruptured 4/28 PM. The plan included general surgery consulted, computed tomography (CT) scan of the right lower extemity without evidence soft tissue gas, unable to rule out infectious phlegmon (inflammation of soft tissue that spreads under the skin or inside the body. It's usually caused by an infection and produces pus); suspect will need further imaging, wound care consulted.

Review of the After Visit Summary signed by the physician on 05/06/21 revealed a referral was made for the patient to receive home health services for wound care (coccyx wound - chronic and present on admission). The orders for the coccyx wound included every other day dressing changes with Aquacel Ag (dressing containing silver that is used for infected wounds) and a bordered foam. The discharge instructions included a follow up appointment with general surgery for a biopsy of the soft tissue mass. There were no instructions for care regarding the back of the patient's right leg where the blister had been unroofed. The findings were confirmed with Staff M on 05/25/21 at 5:30 PM.

This substantiates Substantial Allegation OH00122319.