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Based on observation, document review, and staff interview, it was determined the hospital failed to complete an updated assessment once a patient was transported back to the care unit floor after they had received a procedural service. This failure had the potential to have an adverse effect on one (1) out of one (1) patient, patient #1.

Review of patient #1's medical record revealed there was no evidence of an Assessment Report being completed on July 10, 2023, after the patient returned to L8 floor by a registered nurse.

A review of a policy, titled, "Patient Assessment Department: Hospital Wide" revised: March 2021. The policy stated in part, ... Purpose: To provide guidelines for collecting and analyzing data about each patient so appropriate care, treatment and services decision can be made. Responsibilities: ... II. The patient is to be reassessed on an on-going basis and adjustment made accordingly. It is the responsibility of the physician to inform the patient of the diagnosis and proposed treatment. III. It is the responsibility of the registered nurse to assess the patient's needs for nursing care in all settings, as required by law, regulations, and hospital policy. A. It is the responsibility of the registered nurse to accurately complete and document all assessments, within specified departmental time frames and contents. D. Reassessments are to be completed and documented as indicated. E. The registered nurse will notify the physician of abnormal diagnostic test and significant changes in the patient's status or condition ... II. Each patient is reassessed as needed: B. Reassessment may be initiated for any of the following services: ... To respond to a significant change in status and/or diagnosis or condition.

An interview was conducted with the Administrator Director of Performance Improvement and Risk Management (ADPIRM) on August 12, 2023, at 10:00 a.m. The ADPIRM stated, "There is no documentation of any assessment being completed once [Patient #1] was brought back to L8 floor from PACU or any nursing notes completed from the time they came to the eighth floor until discharge."

Based on observation, document review, and interview, the hospital failed to ensure there was an appropriate discharge plan completed to outline the necessary skin wound care and discuss with the patient and their caregiver the proper techniques to care for such a wound. This failure had the potential to have an adverse effect on one (1) out of one (1) patient, patient #1.

A record review of patient #1's Discharge Summary dated July 10, 2023 completed by physician #1 revealed the discharge instructions which states, "Notify physician for fever or chillis; temperature over 100.5 lasting more than eight (8) hours; nausea and/or vomiting more than three (3) times or longer than twenty-four (24) hours; constipation, no bowel movement in three (3) days or longer, shortness of breath, chest pains, redness, swelling, warmth, pain at intravenous (IV) access/device site; redness, swelling warmth around incision, bleeding or drainage from incision, severe weakness or tiredness; severe pain that pain medication does not control, if symptoms worsen contact your health care provider or call 911 if you are over age sixty-five (65) and have not received both pneumococcal vaccinations or you are under the age of sixty-five (65) with chronic immunodeficiency, renal disease, cardiovascular disease, pulmonary disease, diabetes, liver disease, alcoholism or you are a smoker and have not received pneumovax vaccination may be indicated. Please follow up with your primary care physician after discharge for potential vaccinations. Reviewed discharge instructions with patient/significant other/caregiver, patient/significant, other/caregiver verbalized understanding instruction, patient/significant other/caregiver received written instruction." There is no evidence mentioning in the discharge plan of the care of any skin wound care.

A review of the policy, titled "Discharge Planning: Hospital Wide" lasted revised: December 2021. The policy stated, in pertinent part, "... Purpose: To assure that discharge planning, based on the patient's continuing needs, occurs without disruption to the patient's care in a timely, efficient, and effective manner ... Responsibilities: II. It is the responsibility of the physician in collaboration with other health care professional and the patient and/or caregiver to determine the disposition of the patient. The physician is responsible for writing specific discharge instructions. III. It is the responsibility of the appropriate health care professional to provide the patient/caregiver with verbal and written discharge instructions and ascertain patient/caregiver understanding ... Guidelines: ... II. Each patient released from the system receives on discharge a written plan of instructions for medication, treatment, necessary follow-up, and additional information as appropriate. Discharge instructions are verbally reviewed with the patient and/or caregiver prior to services." There was no evidence that the skin wound care was addressed in the discharge summary.

An interview was conducted with the Physician #1 on August 12, 2023, at 10:06 a.m. The physician #1 stated, "I am [patient #1's] PCP and attending physician of the case at the hospital. I was not aware of the skin tear that happen on July 10, 2023, upon discharge. I was involved in the patient discharge plan. I would have addressed the skin tear on the discharge plan if I had known about it at the time of discharge. The anesthesiologist addressed the skin tear in the PACU. When I became aware of the skin tear was on July 11, 2023, when the spouse contacted me at my office stating that the wound was still bleeding. I scheduled a follow up appointment on July 14, 2023. I addressed how to care for the skin tear during the office visit. I discussed with the patient and spouse that the wound needed to be kept dry and covered, watch for redness if there were any changes call my office. I seen the patient on September 6, 2023, the skin tear was healing. I seen the patient on September 27, 2023, to receive a B-12 shot and the skin tear had healed. I do not know how the skin tear happened, but it was handled properly. This patient has pancreatitis disease which might have caused the skin to become thin, also the patient has low albumin which also might cause the skin to become thin."

An interview was conducted with the Administrator Director of Performance Improvement and Risk Management (ADPIRM) on August 12, 2023, at 10:00 a.m. The ADPIRM stated, "There is no documentation of any assessment being completed once Patient #1 was brought back to L8 floor from PACU or any nursing notes completed from the time they came to the eighth floor until discharge. The ADPIRM also concurred that there was no mention in the discharge summary on how to care for the skin tear which they received during the endoscopy procedure."