HospitalInspections.org

Based on interview and record review the hospital failed to ensure that the discharge summary for 1 of 5 sampled patients (Patient 5) recapitulated the patient's altered skin integrity that required treatment during the patient's hospital stay. The physician discharge summary failed to address the recommendations for future care of Patient 5's Stage 2 pressure ulcers (a bedsore that has developed open shallow breaks in the skin). These failures had the potential to contribute to harm to the patient due to a potential lack of follow up care for the patient's Stage 2 pressure ulcers.

Findings:

On January 22, 2013, Patient 5's medical record was reviewed with the wound care nurse (WCN) and showed that the patient was admitted to the hospital on January 7, 2013 with a diagnosis of scrotal mass.

A review of the photographic documentation dated January 7, 2013 showed that the patient was admitted with a Stage 2 pressure ulcer on the left and the right buttocks.

A review of the Physician Discharge Orders, Instructions and Transfer Summary dated January 11, 2013 showed the following: "Patient Education/Instructions: Pressure ulcer and incision care/dress(ing) changing."

A review of the discharge summary for Patient 5, which was dictated on January 14, 2013, failed to show that the patient received care and services throughout the hospital stay for the Stage 2 right and left buttocks pressure ulcers. The discharge summary failed to identify the buttocks wounds as pressure ulcers and failed to document the treatment recommendations for the pressure ulcers. The documentation in the discharge summary was as follows, "The patient also stated that he has significant sloughing (peeling off) of the skin on his buttocks of unknown duration."

During an interview on January 22, 2013 at 1:45 PM the WCN acknowledged that the physician discharge summary should have shown the care and services that the patient received for the pressure ulcers, the recommended treatment at discharge and the discharge summary should have identified the patient's wounds as Stage 2 pressure ulcers.


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