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Based on review of clinical records, documents and staff interview it was determined the registered nurse failed to reevaluate and measure the patient's wound prior to discharge as required. This failure impacted one (1) of three (3) closed/discharge records reviewed (patient #1) and has the potential to adversely impact the condition of all patients with wounds.

Findings include:

1. Review of the clinical record for patient #1 revealed the patient had a wound on her coccyx. Review of nursing documentation revealed it was measured and a dressing was applied on 3/31/17. Nursing documentation reflected the dressing was changed on 4/2/17. There was no wound measurement recorded on 4/2/17 or 4/3/17. The patient was discharged on 4/3/17.

2. The current Lippencott Procedures for Wound Assessment and Pressure Injury prevention were provided for review when the hospital's wound care polices were requested on 7/31/17. The Wound Assessment procedures stated in part, "You should complete a comprehensive wound assessment during every dressing change..." The Pressure Injury prevention procedure states in part, "Perform a comprehensive skin assessment on a patient's admission to the unit, daily, and on transfer or discharge."

3. On 8/1/17 at 8:30 a.m. the clinical record for patient #1 and the hospital's expectations for wound care and assessment documentation were reviewed and discussed jointly with the 7 South Nurse Manager, 7 S Clinical Coordinator and 7 S Discharge Nurse. They agreed the record lacked a re-evaluation with wound measurement prior to discharge as required.

Based on clinical record review, document review and staff interview it was determined the hospital failed to ensure wound care was included in the discharge instructions provided to one (1) of three (3) discharged patients reviewed (patient #1). This failure creates the potential for an adverse impact on the post-discharge needs of all patients.

Findings include:

1. Review of the clinical record for patient #1 revealed she had a wound on her coccyx and was discharged on 4/3/17.

2. The 2/16/17 policy for Interdisciplinary Plan of Care, and 4/7/17 policy for Patient Discharge were provided for review on 7/31/17. The Interdisciplinary Plan of Care policy states in part: "The attending physician is ultimately responsible for the patient plan of care and will take the necessary steps during the course of the patient's treatment to see that arrangements for discharge are being made concurrently with treatment." The Patient Discharge policy states in part, "Follow-up/continuing care and instructions are addressed as part of the discharge process."

3. Review of the 4/2/17 Discharge Summary completed by the physician revealed it made no mention of the patient's coccyx wound. Review of the 4/3/17 Discharge Instructions, Orders and Medications provided to the patient revealed no mention of the coccyx wound.

4. The clinical record for patient #1 was reviewed and discussed with the 7 South Nurse Manager, 7 S Clinical Coordinator and 7 S Discharge Nurse at 8:30 a.m. on 8/1/17. The Discharge Nurse noted the Discharge Instructions are generated by the physician and require review to ensure all necessary post hospital patient care information is included. The Clinical Coordinator and Nurse Manager acknowledged the Discharge Instructions provided to patient #1 failed to include any information or instruction related to care for the coccyx wound.