HospitalInspections.org

Based on interview and record review, the facility failed to include an evaluation of the patient's likelihood of needing post-hospital services and of the availability of those (Home Health Services and Wound Care) services; to arrange for home health services for wound care management upon discharge to an ALF (Assisted Living Facility); to reassess the patient's discharge plan for factors that affected the continuing care needs and the appropriateness of the discharge plan; and to refer the patient to the appropriate facilities, agencies, or outpatient services, for wound care in 1 (SP #1) of 7 sampled patients. (Refer to A- 806, A-820, A-821, A-837). This failure resulted in the patient not receiving wound care services after discharge.

Based on interview and record review the facility failed to include an evaluation of 1 (SP #1) of 7 sampled patients likelihood of needing post-hospital services and of the availability of those (Home Health Services and Wound Care) services.

The findings include:

Record review of sample patient (SP) #1 showed that the patient presented to the ED (Emergency Department) on 08/26/2018 around 18:48 pm via ambulance with the chief complaint taken as ambulance was called out to the ALF(Assisted Living Facility) because patient fell from the bed and found her on the floor, bleeding from the head." Patient was noted with history of Alzheimer dementia, bed-bound and nonverbal, Parkinson's disease, CVA, sacral decubitus ulcer.


Sample patient #1 was seen by the wound care nurse on 08/27/2018 . Telephone Orders were received on 08/27/2018 at 13:33 pm for wound care. The presence of stage II right sacral decubitus, and an unstageable deep tissue injury on the left heel measuring 5 X 6 cm were identified by the wound care nurse as pre-exiting condition prior to admission. Wound care orders were provided and done to include care for the right arm and forearm skin tears to be cleaned with normal saline and pat dry daily; for the right buttock stage 2 pressure injury to be cleaned with normal saline, pat dry, skin prep peri-wound, apply hydrogel, and cover with Mediplex border the sacrum daily; for the Left Heel apply betadine paint, wrap with Kerlix. Apply Z-flex boot on both heels daily.

The Transition Planning Initial Assessment for discharge on 08/27/2018 at 13:51 pm showed for home environment, current home treatments: none. Discharge needs I: Discharge plan/needs: no discharge data available. Discharge needs II Devices/Equipment: none.

The Transition Planning Follow up for discharge entered on 08/29/2018 at 14:15 pm did not show a reassessment of the sample patient #1 discharge needs to show that wound care was needed and HHA services.

Discharge Plan per Family, and ALF Owner was for the patient (SP #1) to return to the ALF (Assisted Living Facility).

Sample patient #1 did not meet admission criteria to reside in the ALF without hospice/HHA services.

On 08/29/2018 the attending physician noted that patient was at baseline based on conversation with the ALF owner. Patient was discharged back to the ALF via ambulance on 08/29/2018 around 17:05 PM. The attending physician did not write discharge orders for HHA services or for wound care.

There was no evidence to show specific follow up for wound care orders, instructions or referral for home health services (HHA or hospice) to provide wound care to the decubitus.

The ALF facility did not have any documentation that SP #1 wound care was provided after discharge from the hospital on 08/29/2018.

Interview with the Wound Care Nurse on 12/18/2018 around 12:40 PM showed that the intent was to continue wound care at the ALF upon discharge and that had she known she would have reminded the attending physician to write the orders.

Interview with the attending physician on 12/18/2018 around 02:40 PM showed that she was aware the patient came in with wounds, and pressure sores and that treatment was provided while in the hospital. The discharge instructions included a follow up visit with the primary care physician within 3 days.

Based on interview and record review, the facility failed to arrange for 1 (SP#1) of 7 sampled patients home health services for wound care management upon discharge to an ALF (Assisted Living Facility) to prepare for her post-hospital care.


Findings Include:

Record review of sample patient (SP) #1 showed that the patient presented to the ED (Emergency Department) on 08/26/2018 around 18:48 pm via ambulance with the chief complaint taken as ambulance was called out to the ALF(Assisted Living Facility) because patient fell from the bed and found her on the floor, bleeding from the head." Patient was noted with history of Alzheimer dementia, bed-bound and nonverbal, Parkinson's disease, CVA, sacral decubitus ulcer.


Sample patient #1 was seen by the wound care nurse on 08/27/2018 . Telephone Orders were received on 08/27/2018 at 13:33 pm. The presence of stage II right sacral decubitus, and an unstageable deep tissue injury on the left heel measuring 5 X 6 cm were identified by the wound care nurse as pre-exiting condition prior to admission. Wound care orders were provided and done to include care for the right arm and forearm skin tears to be cleaned with normal saline and pat dry daily; for the right buttock stage 2 pressure injury to be cleaned with normal saline, pat dry, skin prep peri-wound, apply hydrogel, and cover with Mediplex border the sacrum daily; for the Left Heel apply betadine paint, wrap with Kerlix. Apply Z-flex boot on both heels daily.

The Transition Planning Initial Assessment for discharge on 08/27/2018 at 13:51 pm showed for home environment, current home treatments: none. Discharge needs I: Discharge plan/needs: no discharge data available. Discharge needs II Devices/Equipment: none.

The Transition Planning Follow up for discharge entered on 08/29/2018 at 14:15 pm did not show a reassessment of the sample patient #1 discharge needs to show that wound care was needed and HHA services.

Discharge Plan per Family, and ALF Owner was for the patient (SP #1) to return to the ALF (Assisted Living Facility).

Sample patient #1 did not meet admission criteria to reside in the ALF without hospice/HHA services.


On 08/29/2018 the attending physician noted that patient was at baseline based on conversation with the ALF owner. Patient was discharged back to the ALF via ambulance on 08/29/2018 around 17:05 PM. The attending physician did not write discharge orders for HHA services or for wound care.

There was no evidence to show specific follow up for wound care orders, instructions or referral for home health services (HHA or hospice) to provide wound care to the decubitus.

The ALF facility did not have any documentation that SP #1 wound care was provided after discharge from the hospital on 08/29/2018.

Interview with the Wound Care Nurse on 12/18/2018 around 12:40 PM showed that the intent was to continue wound care at the ALF upon discharge and that had she known she would have reminded the attending physician to write the orders.

Interview with the attending physician on 12/18/2018 around 02:40 PM showed that she was aware that patient came in with wounds, and pressure sores and that treatment was provided while in the hospital. The discharge instructions included a follow up visit with the primary care physician within 3 days.

Based on interview and record review, the facility failed to reassess the patient's discharge plan for factors that affected continuing care needs and the appropriateness of the discharge plan in 1 of 7 Sample Patient (SP#1).

Findings Include:

Record review of sample patient (SP) #1 showed that the patient presented to the ED (Emergency Department) on 08/26/2018 around 18:48 pm via ambulance with the chief complaint taken as ambulance was called out to the ALF(Assisted Living Facility) because patient fell from the bed and found her on the floor, bleeding from the head." Patient was noted with history of Alzheimer dementia, bed-bound and nonverbal, Parkinson's disease, CVA, sacral decubitus ulcer.

Sample patient #1 was seen by the wound care nurse on 08/27/2018. Telephone Orders were received on 08/27/2018 at 13:33 pm. The presence of stage II right sacral decubitus, and an unstageable deep tissue injury on the left heel measuring 5 X 6 cm were identified by the wound care nurse as pre-exiting condition prior to admission. Wound care orders were provided and done to include care for the right arm and forearm skin tears to be cleaned with normal saline and pat dry daily; for the right buttock stage 2 pressure injury to be cleaned with normal saline, pat dry, skin prep peri-wound, apply hydrogel, and cover with Mediplex border the sacrum daily; for the Left Heel apply betadine paint, wrap with Kerlix. Apply Z-flex boot on both heels daily.

The Transition Planning Initial Assessment for discharge on 08/27/2018 at 13:51 pm showed for home environment, current home treatments: none. Discharge needs I: Discharge plan/needs: no discharge data available. Discharge needs II Devices/Equipment: none.

The Transition Planning Follow up for discharge entered on 08/29/2018 at 14:15 pm did not show a reassessment of the sample patient #1 discharge needs to show that wound care was needed and HHA services.

Discharge Plan per Family, and ALF Owner was for the patient (SP #1) to return to the ALF (Assisted Living Facility).

Sample patient #1 did not meet admission criteria to reside in the ALF without hospice/HHA services.


On 08/29/2018 the attending physician noted that patient was at baseline based on conversation with the ALF owner. Patient was discharged back to the ALF via ambulance on 08/29/2018 around 17:05 PM. The attending physician did not write discharge orders for HHA services or for wound care.

There was no evidence to show specific follow up for wound care orders, instructions or referral for home health services (HHA or hospice) to provide wound care to the decubitus .

The ALF facility did not have any documentation that SP #1 wound care was provided after discharge from the hospital on 08/29/2018.

Interview with the Wound Care Nurse on 12/18/2018 around 12:40 PM showed that the intent was to continue wound care at the ALF upon discharge and that had she known she would have reminded the attending physician to write the orders.

Interview with the attending physician on 12/18/2018 around 02:40 PM showed that she was aware that patient came in with wounds, and pressure sores and that treatment was provided while in the hospital. The discharge instructions included a follow up visit with the primary care physician within 3 days.

Based on interview and record review, the facility failed to refer the patient to the appropriate facilities, agencies, or outpatient services, for wound care in 1 of 7 Sample Patient (SP#1).

Findings Include:

Record review of sample patient (SP) #1 showed that the patient presented to the ED (Emergency Department) on 08/26/2018 around 18:48 pm via ambulance with the chief complaint taken as ambulance was called out to the ALF(Assisted Living Facility) because patient fell from the bed and found her on the floor, bleeding from the head." Patient was noted with history of Alzheimer dementia, bed-bound and nonverbal, Parkinson's disease, CVA (stroke), sacral decubitus ulcer.


Sample patient #1 was seen by the wound care nurse on 08/27/2018. Telephone Orders were received on 08/27/2018 at 13:33 pm. The presence of stage II right sacral decubitus, and an unstageable deep tissue injury on the left heel measuring 5 X 6 cm were identified by the wound care nurse as pre-exiting condition prior to admission. Wound care orders were provided and done to include care for the right arm and forearm skin tears to be cleaned with normal saline and pat dry daily; for the right buttock stage 2 pressure injury to be cleaned with normal saline, pat dry, skin prep peri-wound, apply hydrogel, and cover with Mediplex border the sacrum daily; for the Left Heel apply betadine paint, wrap with Kerlix. Apply Z-flex boot on both heels daily.

The Transition Planning Initial Assessment for discharge on 08/27/2018 at 13:51 pm showed for home environment, current home treatments: none. Discharge needs I: Discharge plan/needs: no discharge data available. Discharge needs II Devices/Equipment: none.

The Transition Planning Follow up for discharge entered on 08/29/2018 at 14:15 pm did not show a reassessment of the sample patient #1 discharge needs to show that wound care was needed and HHA services.

Discharge Plan per Family, and ALF Owner was for the patient (SP #1) to return to the ALF (Assisted Living Facility).

Sample patient #1 did not meet admission criteria to reside in the ALF without hospice/HHA services.


On 08/29/2018 the attending physician noted that patient was at baseline based on conversation with the ALF owner. Patient was discharged back to the ALF via ambulance on 08/29/2018 around 17:05 PM. The attending physician did not write discharge orders for HHA services or for wound care.

There was no evidence to show specific follow up for wound care orders, instructions or referral for home health services (HHA or hospice) to provide wound care to the decubitus.

The ALF facility did not have any documentation that SP #1 wound care was provided after discharge from the hospital on 08/29/2018.

Interview with the Wound Care Nurse on 12/18/2018 around 12:40 PM showed that the intent was to continue wound care at the ALF upon discharge and that had she known she would have reminded the attending physician to write the orders.

Interview with the attending physician on 12/18/2018 around 02:40 PM showed that she was aware that patient came in with wounds, and pressure sores and that treatment was provided while in the hospital. The discharge instructions included a follow up visit with the primary care physician within 3 days.