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Based on a review of hospital policies, patient records, and staff interviews, the hospital failed to ensure that a patient's discharge plan was consistent with their goals for post-discharge care after the hospital failed to ensure a provider arranged the appropriate post-surgery follow-up including the removal of surgical staples and wound care in accordance with the patient's discharge needs (A-0813).

Based on record review and staff interviews, the hospital failed to ensure that discharge instructions were documented in accordance with hospital policy for 1 of 4 patients reviewed who underwent surgical procedures at the hospital (Patient ID #2). Additionally, Patient ID #2's medical record failed to reveal evidence that arrangements were made with the appropriate provider for the removal of surgical staples and wound care in accordance with the patient's discharge needs following surgery.

Findings are as follows:

A complaint submitted to the Rhode Island Department of Health alleged in part that a upon discharge, the Physician (Employee A) gave Patient ID #2 a staple remover and told him/her to "find someone to remove the staples in a few days or watch a video and do it yourself."

Record review revealed that Patient ID #2 presented to the hospital in April of 2025 complaining of abdominal pain. The patient was subsequently admitted for surgery after diagnostic imaging confirmed evidence of acute appendicitis (inflammation of the appendix).

The record indicated that on 4/19/2025, Patient ID #2 initially underwent a laparoscopic appendicectomy (a surgical procedure used to remove inflamed appendix), however, during the initiation of this surgery, it was determined that the patient's appendix had perforated, and the surgery was converted into an open ileocolectomy (a surgical procedure used to remove sections of the small and large intestines). A "midline incision was made above the umbilicus (navel)" and parts of the intestines were removed, the internal suturing was applied, and the skin was closed with "staples."

Review of Patient ID #2's medical record failed to reveal documentation of the wound status at discharge, nor evidence that arrangements were made for surgical follow-up, wound evaluation, or staple removal. Additionally, the record failed to reveal documentation that the patient had been instructed to monitor for wound complications or signs of infection, nor were wound care instructions documented.

During a surveyor interview with Patient ID #2 on 9/19/2025 at approximately 10:45 AM, the patient presented a photo of their surgical incision taken approximately two days following discharge from the hospital. The image showed a midline abdominal incision extending above the navel. Approximately seven surgical staples were clustered near the navel. The image revealed that there were only two staples along the superior portion of the incision line, with three open areas where the skin edges were not close together resulting in exposed underlying tissue.

During a surveyor interview with the Director of Risk Management on 9/18/2025 at approximately 2:00 PM, she was unable to provide evidence that Employee A documented Patient ID #2's discharge instructions related to wound care, signs of infection and complications, and follow up arrangements for wound evaluation and staple removal, in accordance with hospital policy.