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Based on interviews, clinical record review, document review, and in the course of a complaint investigation, it was determined the facility staff failed to complete admission assessments and shift assessments as directed by facility policy, for 2 of 12 sampled inpatients (Patient #3 and #4).

The findings include:

1. Facility staff members failed to complete the admission assessment and a morning shift assessment for Patient #4.

Patient #4 was admitted to the facility on 2/9/17 and discharged on 2/13/17. Patient #4 had an admitting diagnosis of right femoral neck fracture and hypertensive urgency. The clinical record was reviewed on 7/13/17 with the assistance of Staff Member (SM) #15 as the chart navigator.

Review of the clinical record failed to provide evidence of an admission assessment completed at any time during the patient's stay and failed to provide evidence of a shift assessment with the transfer of care on the morning of 2/9/17.

The following information was found in a facility policy titled "Assessment/Reassessment, Patients" (effective date - 1/2011; last revised date - 4/2013) follows:

B. Initial inpatient assessment
3. The RN is responsible for reviewing and assuring completion of the Admission History Database within the appropriate time-frames.

Contained within the aforementioned policy under the heading "References" is an "Assessment / Reassessment Grid" which designates the Registered Nurse as responsible for a "Head to Toe physical assessment within 8 hours and the remainder in 24 hours". The "Assessment / Reassessment Grid" also directs that "Each inpatient is reassessed: - when care is transferred from one care giver to another".

The above information was shared with SM #2 (Senior Director of Quality) during the survey and for a final time on 7/19/17 at 5:30 PM. No further information was provided to the survey team.

2. Findings related to Patient #3's clinical record review occurring 12/21/16 through 01/12/17.

The surveyor was navigated through the Electronic Medical Record by (Staff Member (SM) #6).

On 12/21/16 at 6:43 AM, Patient #3 was admitted, as an inpatient, with a fractured left hip. According to the medical record an initial admission assessment was never completed by a Registered Nurse (RN).

A. Patient #3 left the Emergency Department (ED) with 02 (oxygen) at 2L/NC (nasal cannula) per physician's order. At 9:54 AM, a Respiratory Therapist (RT) documented "02 at 5L". At 6:31 PM, a RT documented, "pt [patient] tolerating the bipap [noninvasive positive pressure ventilation] will get abg [arterial blood gas] at 1900 [7:00 PM]" [Sic]. There was no nursing assessment noted in the medical record regarding a change in the patient's respiratory status.

The facility's nursing staff failed to complete shift assessments for the following shifts:

12/24/16 no PM shift assessment completed.
01/02/17 no PM shift assessment completed.
01/07/17 no PM shift assessment completed.
01/08/17 no PM shift assessment completed.
01/09/17 no AM shift assessment completed.

The facility's staff failed to consult the wound care nurse and or notify the physician of Patient #3's change in skin integrity.

A review of Patient #3's clinical record was conducted on 07/12/17 at 2:00 PM. On 01/03/17 at 2:00 PM, the nursing assessment documentation stated: "Comments: Has blister on right shoulder has blister on right hip MEPILEX [foam dressing suitable for a wide range of wounds] intact". [Sic]

On 01/03/17 at 10:25 PM, the nursing assessment documentation stated:
"Additional Wounds: Y
Site: RT HIP RT SHOULDER
Wound Type: Ulcer
Severity: Superficial
Dressing: MEPILEX
Comments: RT HIP BLISTER AND SKIN AS TORN." [Sic]

On 01/03/17 at 10:24 PM, documentation in the nurse's note stated: Pt [patient] moans when turned. Unable to rate pain. Pain med given. Replaced MEPILEX to right hip due to blister that appears to have popped. Serous drainage leaking out from torn skin. Also placed new MEPILEX to Rt shoulder where there appears to be a new blister forming. Skin is dark and boggy. Placed MEPILEX to left shoulder for protection and to left hip where there is a rough area of skin." [Sic]

On 01/03/17 at 2:00 PM, the nursing assessment documentation stated:
"Comments: has blister on right shoulder has blister on right hip mepilex [foam dressing suitable for a wide range of wounds] intact" [Sic].

On 01/03/17 at 10:25 PM, the nursing assessment documentation stated:
"Additional Wounds: Y
Site: RT HIP RT SHOULDER
Wound Type: Ulcer
Severity: Superficial
Dressing: MEPILEX
Comments: RT HIP BLISTER AND SKIN AS TORN." [Sic]

On 01/08/17 at 10:00 AM, the nursing assessment documentation stated:
"Site: RIGHT HIP RIGHT SHOULDER
Wound Type: Ulcer
Severity: Superficial
Dressing: MEPILEX".

On 01/09/17 at 8:37 PM, documentation in the nurse's note read in part as follows: Changed MEPILEX to right hip blister. Placed a Telfa dressing [non-adhering dressing] with Vaseline and MEPILEX. Nursing replaced the MEPILEX dressing to patient's sacrum and left hip. [Sic]

On 01/10/17 at 9:25 AM, the nursing assessment documentation stated:
"Additional Wounds: Y
Site: RT HIP RT SHOULDER
Wound Type: Ulcer
Drainage amount: None/dry
Dressing: MEPILEX".

On 01/10/17 at 8:26 PM nursing assessment documentation stated:
"Comments: BLISTER TO RT HIP -VASOLINE/TELFA/MEPILEX RT SHOULDER BOGGY - MEPILEX."

On 07/12/17 at 2:40 PM an interview was conducted with SM #2. SM #2 stated it would be the facility's expectation that patient's admission assessment and reassessment be completed as noted in the policies and procedures. He/she would expect nursing to complete a focused assessment if there were changes in the patient's condition.

Findings related to facility documents and or policies and procedures were as follows:

The following information was found in a facility policy titled "Assessment/Reassessment, Patients" (effective date - 01/2011; review/revise date - 08/2016) read in part as follows:

"PROCEDURE
A. Initial Assessment
1. An initial assessment will be performed by a Registered Nurse. Some aspects of data collection may be delegated to the LPN or CA as appropriate. The patient's plan of care is developed by the RN as determined by the care needs and priorities identified in the patient assessment. The remainder of the assessment includes Medical/Surgical History.

2. The format and scope of the initial database assessment is specific and appropriate to the patient and care setting. This assessment is to include physiological, psychological, cognitive, communicative, development and social parameters as defined in the documentation tool for the specific patient/setting.

"C. Patient Assessments/Reassessments
1. A complete assessment is performed by the RN every 24 hour period. A focused assessment may be completed by an LPN and reviewed by the RN.
3. A complete assessment is performed by the RN:
c. When there is any significant change in a patient's condition.
4. A problem focused re-assessment may be conducted by a RN or designate LPN as determined appropriate. The patient is re-assessed:
a. When care is transferred from one caregiver to another (i.e., change of shift) (LPN - Licensed Practical Nurse)

On 07/18/17 at 3:25 PM, SM #2 presented the surveyors with this document. The document titled, "NURSING PROTOCOL DICTIONARY" and reads in part as follows:

"DESCRIPTION Standard of Care: Med/Surg

ROUTINE CARE: MED/SURG
10. Physician will be notified of significant changes inpatient status as defined by physician order and/or nursing assessment/reassessment and nursing judgment. Nursing will document physician notification.

In the afternoon of 07/13/17 an interview was conducted with SM #6. SM #6 stated, he/she was unable to find any documentation in the clinical record that the wound nurse had been consulted or the physician had been made aware of the wounds. He/she stated, I would expect to find documentation in the clinical record if the wound nurse or the physician had been notified."

On 07/18/17 at 3:25 PM, SM #2 presented the surveyors with this document. The document titled, "NURSING PROTOCOL DICTIONARY" and reads in part as follows:

"DESCRIPTION Standard of Care: Med/Surg

ROUTINE CARE: MED/SURG
10. Physician will be notified of significant changes inpatient status as defined by physician order and/or nursing assessment/reassessment and nursing judgment. Nursing will document physician notification.

SKIN INTEGRITY:
11. Consult wound care nurse to assist in addressing wound care needs."

The above findings were discussed with the management team on 07/13/17 at the end of day meeting. No further information was provided to the survey team.

Based on staff interviews, clinical record review, document review, and in the course of a complaint investigation, it was determined the facility staff failed to consistently complete all aspects of the discharge planning process for 7 of 12 sampled patients reviewed for discharge planning. (Patient #1, #2, #3, #4, #9, #13 and #14)

The findings include:

Patient #1's discharge paperwork did not include a complete reconciled medication list which addressed home, current and discharge medications. The medication reconciliation failed to address an anticoagulant the patient was receiving in hospital and listed to be continued in the dictated discharge summary.

Patient #2's discharge paperwork did not receive a complete reconciled medication list which addressed home, current and discharge medications. The medication reconciliation failed to address an anticoagulant and pain medications the patient was receiving in hospital and were listed to be continued in the dictated discharge summary.

Patient #3's the facility's staff failed to provide the Home Health agency with the patient's current discharge information. The facility's staff failed to educate/teach the patient and or patient's caregiver on how to administer Lovenox injection post discharge.

Patient #4's discharge process failed to provide a clear and easily understood list of medications to be taken after discharge. The medication reconciliation failed to provide clear instructions related to the administration of an antibiotic.

Patient #9's discharge instructions and medication reconciliation failed to resolve discrepancies related to administration of insulin.

Patient #13's clinical record failed to provide evidence facility staff obtained a list of home medications as a part of the medication reconciliation process.

Patient #14's clinical failed to provide evidence staff followed facility policy when a nurse completed the medication reconciliation process for the physician.


Please see A-820 and A-823 for additional details.

Based on staff interviews, clinical record review, document review, and in the course of a complaint investigation, it was determined the facility staff failed to: a) ensure the medication reconciliation process captured and addressed all medications the patient should be taking after discharge with clear indications of changes from pre-admission medications; b) educate and instruct patients and/or caregivers on new medications or care required post discharge for 7 of 12 sampled patients reviewed for discharge planning. (Patient #1, #2, #3, #4, #9, #13 and #14)

The findings include:

1. Patient #1's clinical record was reviewed on 7/12/17 with the assistance of a chart navigator Staff Member (SM) #7. Patient #1 was admitted to the facility on 2/1/17 for sepsis and respiratory failure. During the hospital stay the patient developed tachycardia (rapid heartbeat) and was evaluated by a cardiologist. The cardiologist noted the tachycardia was atrial flutter (cardiac arrhythmia in which the atrial contractions are rapid, but regular). Lopressor (used to treat cardiac irregularities, hypertension, etc.) was recommended for rate control and Eliquis was recommended for anticoagulation. Patient #1 received Lopressor and Eliquis during the hospital stay beginning 2/3/17. The patient was discharged home with home health on 2/4/17. Surveyor review of discharge documents revealed the following:

.Review of the clinical record document titled "Discharge Summary and Patient Instructions"(the document the patient receives at discharge) revealed the following under the heading "NEW Medications to Start" Lopressor 50mg/5ml Oral, twice daily; Lisinopril 10mg oral daily; Levaquin 500mg oral daily and Lopressor 50mg oral, twice daily. Several medications were listed to continue and no medications were listed to be stopped. The patient had been taking 20mg of Lisinopril daily prior to this admission. The discharge instructions failed to list Eliquis as a new medication, to be continued or to stop taking.

Review of clinical record document titled "Discharge Summary" (a document the patient does not routinely see) revealed the following in part under the heading "Discharge Plan", "3. Atrial Flutter: -Patient started on Lopressor 50 milligrams b.i.d.; -Patient also started on Eliquis 5 milligrams b.i.d. per Cardiology". Under the heading "Reconcile Medications", Eliquis was not addressed but Lopressor, Lisinopril were listed as new medications to start.

The "Discharge Summary" dictated by the physician on 2/4/17 indicated that Eliquis was started during the hospital stay and was administered during the hospital stay, however Eliquis was not addressed by the medication reconciliation process. The medication reconciliation process also failed to address that Lopressor was listed twice under new medications to start, which leaves the dosage unclear. The clinical record failed to provide evidence the patient and/or caregivers received education related to new medications given or started while the patient was hospitalized.

SM #7, a clinical analyst assisting the surveyor with chart review, was unable to determine why Eliquis was not addressed during the medication reconciliation at discharge. It is a possibility the patient was given a prescription for Eliquis by the consulting cardiologist but the record failed to provide evidence of a scanned prescription or of a physician's note.

Review of facility policy "Medication Reconciliation" last revised 3/2015 revealed the following in part "3. Any discrepancies, (omissions, duplications, adjustments, deletions, additions) are reconciled and documented while the patient is under the care of the hospital." and "C. The medications will be reconciled by the provider at discharge and includes review of the pre-admission/home medications and current medications."

The patient is given a copy of the "Discharge Summary and Patient Instruction Sheet" at discharge. The document titled "Discharge Summary" which is dictated by the physician is not routinely given to the patient. The discrepancies between the dictated "Discharge Summary" and the "Discharge Summary and Patient Instruction Sheet" and the concern that the "Discharge Summary and Patient Instruction Sheet" may not accurately reflect the physicians intent or provide an accurate account of medications the patient should be taking after discharge were discussed with the management team the afternoon of 7/12/17, and again on 7/19/17. No further information was provided to the survey team.

2. Patient #2's clinical record was reviewed on 7/12/17 with the assistance of a chart navigator, SM #7. Patient #2 was admitted to the facility on 1/11/17 for a left total hip replacement. During the hospital stay the patient was given Xarelto (an anticoagulant often given to patients after hip or knee surgery to help prevent blood clots) beginning on 1/11/17. The patient was discharged home with home health on 1/13/17. Surveyor review of discharge documents revealed the following:

Review of a scanned in order sheet titled "(insert group name) - Routine Discharge Instructions" read in part under the heading Medications; Use the medications given to you at discharge as directed. 1. for pain: Norco (used to relieve moderate to severe pain) 3. For blood clot prevention ASA 81mg x 3 weeks" (ASA is the abbreviation for aspirin). This document was dated 1/11/17.

Review of clinical record document titled "Discharge Summary" revealed the following in part under the heading "Discharge Instructions", "p.o. Norco for pain, Xarelto for DVT prevention x 3 weeks" (p.o. means orally and DVT is the abbreviation for deep vein thrombosis (blood clot)). There was no medication reconciliation addressed in this document.

Review of the clinical record document titled "Discharge Summary and Patient Instructions" failed to address Xarelto although it was given in the hospital and documented to be continued in the "Discharge Summary" dictated on 1/12/17 and on 2/15/17.

The discrepancies in the medications listed in the discharge papers leaves doubt as to what anticoagulant the patient should be taking after discharge and if he/she had prescriptions/instructions related to pain control. SM #7, who was assisting with the review, was unable to determine why Xarelto was not addressed. The surveyor was informed that some physician groups were having the nurse print the medication list out for the physician to complete as a paper copy. After doing this the nurse would scan the paper into the computer as orders. The clinical record failed to provide evidence of a physician's order related to the completion of the medication reconciliation. The clinical record failed to provide evidence the patient had received the medication reconciliation form as there was no signed copy scanned into the clinical record.

The discrepancies between the dictated "Discharge Summary" and the "Discharge Summary and Patient Instruction Sheet" and the concern that the "Discharge Summary and Patient Instruction Sheet" may not accurately reflect the physicians intent or give an accurate account of medications the patient should be taking after discharge were discussed with the management team the afternoon of 7/12/17, and again on 7/19/17. No further information was provided to the survey team.

3.The facility's staff failed to educate/teach Patient #3 and or patient's caregiver on how to administer Lovenox injections post discharge.

On 07/13/17 at 10:04 AM, SM #6 navigated the surveyor through the clinical records. At discharge Patient #3 was given a prescription for Lovenox (anticoagulant) 40 mg SQ (subcutaneous) daily.

In the afternoon of 07/13/17 an interview with SM #6 was conducted. SM #6 stated, he/she was unable to find any documentation in the clinical record that the nursing staff had educated or taught Patient #3 or patient's caregiver on administering Lovenox injections.

The following information was found in a facility's policy and procedure titled, "Post Transition Planning" (effective date - 01/2004; review/revise date - 07/2015) read in part as follows:

"Procedure
B. All patient care associates will document the patient's transition planning assessment, evaluation, activities and instructions in the patient's medical records using a combination of on -line automation and paper documentation, as appropriate."

The facility's staff failed to obtain an order from the physician to send Patient #3 home with a Foley Catheter (a flexible tube that is passed through the urethra and into the bladder to drain urine.).

On 07/13/17 at 10:21 PM, SM #6 navigated the surveyor through the clinical records. He/she stated she was unable to find a Physicians order to discharge Patient #3 home with a Foley Catheter. There was no documentation in the clinical record that the facility's staff provided post discharge Foley Catheter care to Patient #3 or to the caregiver.

On 07/13/17 at 10:21 PM, an interview was conducted with SM #6. SM #6 stated, there should be a physician's order for a patient to be discharged home with a Foley Catheter.

On 07/13/17 at 9:55 AM, SM #2 presented the surveyors with a document titled, "Lippincott Procedures - Indwelling urinary catheter (Foley) care and management" and reads in part as follows:

"Patient Teaching

If the patient will be discharged home with an indwelling urinary catheter, teach him how to use a leg bag. Instruct the patient to wash the urinary meatus and perineal area with soap and water as part of routine hygiene and the anal area after each bowel movement. Provide the patient and family with information regarding additional methods of infection control as well as the signs and symptoms of urinary tract infection and obstruction. Also review with the patient reasons to notify the practitioner."

The above findings were discussed with the management team on 07/13/17 at the end of day meeting. No further information was provided to the survey team.

4. Patient #4's clinical record was reviewed on 7/13/17 with the assistance of chart navigator, SM #15. Patient #4 was admitted to the facility on 2/6/17 for a right femoral neck fracture. Patient #4 was discharged to a nursing home on 2/13/17. Clinical record document titled "Discharge Summary" reads in part "was treated with Zosyn for 4 days for presumed aspiration pneumonia. Will continue this medication for the next 6 days. "Surveyor review of discharge documents revealed the following under reconcile medications: "Piperacillin Sodium /Tazobactam (Zosyn 3.375 IV) 3.375 G/Vial 3.375GM IV Q8H #5 VIAL, Ref 0). Zosyn is a penicillin type antibiotic used to treat infections.

Review of "Discharge Summary and Patient Instructions" reveals the following under "NEW Medications to start" "Piperacillin Sodium/Tazobactam (Zosyn 3.375 IV) 3.375 G/VIAL. Dose: 3.375 GM INTRAVENEOUS, EVERY 8 HOURS. Qty: 5 Refills: 0." SM #15 and SM # 10 reviewed the instruction with the surveyor and confirmed the instructions for Zosyn were not clear. The quantity "5" could mean 5 doses which would be just under 2 days of medication or 5 days which would still be short of the 6 days stated in the summary. The failure to provide clear instructions for the administration of an antibiotic was discussed with the management team the afternoon of 7/12/17, and again on 7/19/17. No further information was provided to the survey team

5. Patient #9's clinical record was reviewed on 7/13/17 with the assistance of a chart navigator, SM#15. Patient #9 was admitted to the facility on 12/11/16 with a left femoral neck fracture and discharged on 12/13/16 to an inpatient rehabilitation unit.

Survey review of the clinical record revealed a home medication list entered on 12/11/16 consisting of Vitamin D-3, Colace, Lexapro, Neurontin, Hydrodiuril, Prinivil and Pravachol. The form designated there was no attention required. The History and Physical dictated on 12/11/16 at 2:10 AM listed all the aforementioned medications and added Humulin insulin 25 units in the morning and 18 units at night to the medications list. Patient #9's "Discharge Summary and Patient Instructions" lists Lantus 20 units daily as a medication to continue. Review of the medical record failed to provide evidence the Patient was taking Lantus insulin when admitted and failed to provide evidence of the administration of Lantus insulin while Patient #9 was an inpatient. The medication reconciliation list failed to address the patient's use of Humulin and fails to address the patient's use of Levimir while an inpatient.

The possibility of the patient administering an incorrect dose of insulin because there were not clear instructions to discontinue the use of Humulin or Levimir upon discharge, was discussed with the management team on 12/13/17 and again on 12/19/17. No further information was presented to the survey team.

6. Patient #13's clinical record was reviewed on 7/19/17 with the assistance of a chart navigator, SM#6. Patient #13 was admitted to the facility on 06/27/17 with acute respiratory failure and discharged to a nursing facility on 7/3/17. Review of the clinical record revealed facility staff failed to obtain a list of home medications. A progress note dictated on 6/26/17 states "will confirm medications with (insert pharmacy name) ". However the clinical record failed to provide evidence of a list of home medications during Patient 13's stay.

Review of facility policy "Medication Reconciliation" last revised 3/2015 revealed the following in part "3. If the patient does not know their medications or the patients is incapacitated, unresponsive or otherwise unable to provide the data, the nurse or pharmacy designee will contact the next of kin to bring the medications from home." The clinical record failed to provide documentation that this occurred and there was no documentation as to why it was not obtained.

The above findings were discussed with the management team on 7/19/17. It was discussed that although the facility had made changes to the discharge process, Patient #13's clinical record reflects current practice, after the changes were in place. No further information was provided to the survey team

7. Patient #14's clinical record was reviewed on 7/19/17 with the assistance of a chart navigator, SM#6. Patient #14 was admitted to the facility on 07/13/17 left total hip replacement and discharged home on 7/3/17.

During the review of the discharge process the surveyor noted that a nurse had completed the discharge medication reconciliation for the physician. Review of the clinical record revealed a scanned order sheet with the instructions to d/c to home today after patient has physical therapy two times today "on current meds". On 7/19/17 the above information was shared with the management team, it was confirmed this was not an accepted practice, and the facility was working with providers to correct this.

Based on interviews, clinical record review, document review, and in the course of a complaint investigation, it was determined the facility staff failed to provide to the patient a list of providers of post-hospital extended care services, and failed to disclose the facility's financial interest in the service selected to 1 of 7 patients sampled who required post-hospital extended care services. (Patient #9)

The findings include:

The clinical record for Patient #9 was reviewed on 7/13/17 with the assistance of a chart navigator, Staff Member (SM) #11. Patient #9 was admitted to the facility on 12/11/16 with an acute femoral neck fracture. He/she was discharged on 12/13/17 and then admitted to an inpatient rehabilitation unit located within the facility.

The process used to inform patients of their freedom to choose among providers of post-hospital services was reviewed with SM #4, the Director of Case Management. Patients who require post-hospital services are given a list of providers to choose from and after having made a choice the patient is given a "choice letter" with their selection listed. At that time it would be noted if the facility had a financial interest in the selected provider. The letter is signed by the patient and scanned into the clinical record.

Review of the clinical record failed to provide evidence of the Patient being provided with a list of providers of rehabilitation services in the area and failed to provide evidence the Patient was informed of the facility's financial interest in the service selected.

The above findings were shared with SM #2 on 7/18/17. SM #2 informed the survey team that he/she was unable to find evidence the patient was given a list of providers to choose from. The above findings were shared with the management team on 7/19/17. No further evidence or information was provided to the survey team.

Based on interviews, clinical record review, document review, and in the course of a complaint investigation, it was determined the facility's staff failed to ensure information regarding wounds and wound care was given to the Home Health agency providing care to the patient after discharge, for 1 of 12 patients surveyed for discharge planning.
The findings include:
Patient #3 was admitted to the hospital on 12/21/16 and discharged on 1/11/7. The facility staff did not inform the home health agency of the skin breakdown, or the need for wound care.
Patient #3's clinical record revealed nursing staff first documented skin breakdown on 1/03/17 at 2:00 PM.

A nursing assessment was noted for 1/3/17 at 2:00 PM. The assessment included, "Comments: Has blister on right shoulder has blister on right hip MEPILEX [foam dressing] intact."

On 01/03/17 at 10:24 PM, documentation in the nurse's note stated, Pt [patient] moans when turned. Unable to rate pain. Pain med given. Replaced MEPILEX to right hip due to blister that appears to have popped. Serous drainage leaking out from torn skin. Also placed new MEPILEX to Rt shoulder where there appears to be a new blister forming. Skin is dark and boggy. Placed MEPILEX to left shoulder for protection and to left hip where there is a rough area of skin.

On 01/03/17 at 10:25 PM, the nursing assessment documentation stated:
"Additional Wounds: Y
Site: RT HIP RT SHOULDER
Wound Type: Ulcer
Severity: Superficial
Dressing: MEPILEX
Comments: RT HIP BLISTER AND SKIN AS TORN." [Sic]

On 01/08/17 at 10:00 AM, the nursing assessment documentation stated:
"Site: RIGHT HIP RIGHT SHOULDER
Wound Type: Ulcer
Severity: Superficial
Dressing: MEPILEX".

On 01/09/17 at 8:37 PM, documentation in the nurse's note read, Changed MEPILEX to right hip blister. Placed a Telfa dressing (non-adhering dressing) with Vaseline and MEPILEX. Nursing replaced the MEPILEX dressing to patient's sacrum and left hip. [Sic]

On 01/10/17 at 9:25 AM, the nursing assessment documentation stated,
"Additional Wounds: Y
Site: RT HIP RT SHOULDER
Wound Type: Ulcer
Drainage amount: None/dry
Dressing: MEPILEX".

On 01/10/17 at 8:26 PM nursing assessment documentation stated, "Comments: BLISTER TO RT HIP -VASOLINE/TELFA/MEPILEX RT SHOULDER BOGGY - MEPILEX."

No evidence was found of the home health agency being informed of the skin breakdown, wound care prior to the patient's discharge from the facility.

In the morning of 07/18/17 an interview was conducted with the Director of Case Management, Staff Member (SM) #4. He/she stated it would be the facility's expectation that the Home Health agency would receive all discharge information at the time of a patient's discharge.