HospitalInspections.org

Based on record review and interview the facility failed to ensure the assisted living facility (ALF) was notified of 1 patient (9)'s wound care regimen at discharge, out of 13 patients reviewed for discharge planning. The failure to notify the ALF of the patient's status change and wound care orders placed the patient at risk for a delay in treatment. Findings:


Record review on 10/15-16/12 revealed Patient #9 was admitted to the facility on 7/22/12 for treatment of cellulitis on her right leg. Further review of the clinical record revealed that during the hospitalization the Patient had developed wounds to her coccyx, right posterior thigh, left ischeal tuberocity, right heel, fourth toe of the right foot, and right lateral foot.


Review of the discharge coordinators documentation, dated 8/29/12, revealed "This email was sent 8/29/12 1000 [10:00 am] to: [the assisted living homes administrator], "Home health orders have been faxed to Matsu Regional Home Care. They are aware of the 8/30/12 discharge date...resume home health orders and wound care for the right leg."


Review of the physician's progress note dated 9/29/12, provided to the ALF at discharge, revealed there was no information about the new wounds.


Review of the discharge instructions dated 8/30/12, given to the Patient at discharge and sent to the ALF, revealed "wound care to the right leg".


As a result, the Patient and the ALF had not received written instructions on how to treat the other six wounds while waiting 2-5 days for the HHA to initiate services.


During an interview on 10/10/12 at 4:00 pm, the Case Manager stated the facility might not necessarily notify the ALF of a change in wound care because the wounds were to be managed by the HHA.


Review of the facility's policy "Discharge of Patient Process" dated 4/14/12 revealed "Review plan for identified discharge needs" and "Instruct patient about medications, treatments, diet to be continued at home..."