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Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that the staff failed to provide Patient # 1 with completed discharge instructions. This deficient practice posed the risk that the patient and/or their representative received incomplete instructions that provided critical information for management of the patients' home care and to ensure comprehension of health information.

Findings include:

Policy and procedure titled "Discharge Planning" revealed: "...Discharge planning begins during the pre-admission phase of the patient's care to assure that the patient is referred to a proper environment for continuity of care...To identify specific needs a patient might have following discharge...7. Each team member will be responsible for providing patient and family education. 8. Each team member will be responsible for documenting discharge plans and interventions completed by their respective service. 9. Discharge summaries will include medical condition, services provided to patient, and will be completed by discipline(s) within 72 hours of discharge, excluding physicians. 10. Discharge summary copies will be provided to home health services if patient is being discharged to home...."

Policy and procedure titled "Patient Teaching" revealed: "...Patients/Families admitted to Promise Hospital can expect to be provided educational information and training in an interdisciplinary manner as appropriate to the plan of care...1. Patient/Family support/training shall...continue throughout the patient's stay within the facility, and shall culminate upon discharge from the facility. 2. Responsibility for assessment of education need and provision of education is that of the entire interdisciplinary team. 3. Disciplines expert in a particular area of care assume primary responsibility but they are required to share the patient's individual education needs with the team and collaborate on educational activities...5. Education shall include but is not limited to:..Sound medical knowledge regarding the patient's medical diagnosis...Relevant and specific information regarding family members' role in the treatment program. Community educational and support resources. Demonstrations and written instructions regarding home treatment programs...Medications, Procedures and Treatments...Discharge instructions...7. During the patient's hospital stay, patient/family education is noted on the Interdisciplinary Patient/Family Education Record as it is provided...8. The Interdisciplinary Patient/Family Education Record serves to identify:..person(s) provided the educational experience, response to the educational experience...10. Patient/Family education culminates upon discharge from the facility through the provision of written discharge instructions...Interdisciplinary team members document the instructions on a Discharge Instruction Sheet of which a copy is provided to the patient with the original placed in the medical record...11. All care providers are responsible for completing documentation on the Discharge Instruction Sheet by the day of discharge...The nurse will coordinate completion of the Discharge Instruction Sheet...."

Review of medical record for Patient # 1 revealed that insulin teaching or education was not documented in the medical record.

Review of the medical record revealed that there were no discharge orders for wound care, no documented teaching for wound care, and no wound care instructions provided to the patient and family upon patient discharge.

RN # 2 and Employee # 3 confirmed during interview and medical record review on 2-23-18 at 11:00 a.m. that medication discharge instructions provided to the patient and family at discharge instructed the patient to continue insulin after discharge. RN # 2 and Employee # 3 confirmed that there was no insulin teaching or education documented in the medical record.

RN # 2 and Employee # 3 confirmed during interview and medical record review that there were no discharge orders for wound care, no documented teaching for wound care, and no wound care instructions provided to t he patient and family upon patient discharge.