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Based on record review and interview, the facility failed to ensure a registered nurse (RN) supervised and evaluated the care for one (1) of ten sampled patients ( Patient # 1).

Nursing staff :

1. Failed to ensure the patient was given the correct discharge instructions for her type of surgery;

2. Failed to ensure the patient's discharge instructions included care of surgical incision and dressing;

3. Failed to ensure the patient was provided a bath or bathing assistance for 4 of her 5 day inpatient admission.

Findings included:

TX # 00305612

Record review of complaint intake TX # 00305612 showed the following issues: Patient # 1 had surgery at facility on 01-04-19 and was discharged home on 01-10-19. Allegations included :

a. During patient's stay staff failed to bathe / assist to shower;

b. There were no discharge instructions (verbal or in writing) that addressed post-op care for incision or dressing;

b.Discharge instructions sent home with Patient # 1 were for "Knee Replacement" surgery & the patient had undergone "Hip Replacement" surgery.

Additional information supplied in the complaint intake showed a few hours post discharge, Patient # 1's foot, calf, and thigh started swelling. Family called the facility the next day and was told "she was supposed to be keeping her leg elevated." It was alleged this information was not told to them at discharge.

Record review of facility policy titled "Discharge Planning,"revised on 4/10/2017, showed the "After Visit Summary(AVS): provided patient with discharge instructions: any directions that the patient must follow after discharge to attend to any residual conditions that need to be addressed by the patient on an outpatient basis.
The policy also showed the completed Discharge Instruction included an AVS from the patient record and a copy to the patient to include explanations provided by the nurse.

Discharge instruction issues :

Review of Patient # 1's medical record showed Patient # 1 underwent a right total hip arthroplasty (hip replacement) on 01-04-19. Patient # 1's "Discharge Summary," dated 01-10-19, showed she was a 59 year old woman who underwent total hip replacement surgery; she tolerated the procedure well; and case management arranged for physical therapy and durable medical equipment (DME) at home. Physician's documented discharge follow-up information in the record included symptoms to report, as well as to call physician for redness, tenderness or signs of infection ( pain, swelling, redness, etc..). There were no instructions provided in this section concerning care of surgical incision or removal/ changing of surgical dressing. Patient # 1 was discharged on 1/10/19.

During an interview on 03-13-19 at 10:15 AM with Staff J, Registered Nurse (RN)/ charge nurse, she stated patient discharge instructions were included in the "After Visit Summary."

Review Patient # 1's "After Visit Summary" dated 01-10-19, showed 6 pages of written discharge instructions were provided for "Total Knee Replacement , Care After". There was no documentation related to care of surgical incision or dressing removal related to Total Hip Replacement, the actual surgery Patient # 1 had.

Interview at the time of the review with Staff J, Charge RN, she stated that Patient # 1 had been given the wrong discharge instructions. She went on to say it was the responsibility of the nurse to choose the correct instructions. Staff J confirmed there was no specific information related to care of the surgical incision or dressing related to hip replacement surgery.

Bathing /shower assistance issue:

Further review of Patient # 1's medical record with Staff J / RN Charge, showed the section titled "Patient Intervention Flowsheets-Hygiene".

Review of this section for dates 1/5/19 through discharge on 1/10/19 showed Patient # 1 had only one documented bath and this was on 01-5-19 ("maximum assist /bed bath").

Interview with Staff J / RN Charge at time of record review, she stated baths/ showers, and all assistance provided should be documented. Even if the patient could perform independently, it was documented. Usually, a bath or shower would be offered dally. It was always the patient's choice and refusal for assistance should be documented. Staff J said the record showed only one bath for Patient # 1 from 1-05-19 until 1-10-19; with no notations of patient refusal.