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DENVER HEALTH & HOSPITAL AUTHORITY 777 BANNOCK ST DENVER, CO 80204 June 4, 2019
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the facility failed to ensure patients were provided with instructions to care for wounds after discharge in 2 of 7 records reviewed in which patients were discharged home with a wound (Patients #3 and #9).

Findings include:

Facility policies:

The Acute Care Unit policy read, patients are discharged to home or an appropriate setting using an interdisciplinary approach with the physicians, nursing, clinical social work, therapy, pharmacy and other services as appropriate to ensure a safe patient discharge.

The Patient Discharge policy read, the care management team will provide education to the patient/ family in regards to the discharge planning, potential barriers and specific needs for the discharge.

1. The facility failed to provide discharge instructions which stated how to care for and clean wounds after patients were discharged .

a. According to Patient #9's Discharge Summary, she had laparoscopic (a thin tube inserted into the abdomen through a small puncture area) surgery for a perforated (ruptured) appendix on 5/5/19. On 5/7/19 at 10:21 a.m., Physician #6 wrote an order for wound care. The order read the strip tapes over the wounds could stay for seven to 14 days or until they fell off the wounds. Care instructions in the order read, it was permitted to shower and wash incisions daily, but not to submerge the wounds in water for two weeks. Review of the After Visit Summary (AVS), signed by Patient #9's parent on 5/7/19 at 1:20 p.m., revealed even though there was a physician order for specific wound care upon discharge, no instructions on how to clean and care for the wounds were provided to the patient or parents.

On 6/4/19 at 12:38 p.m., an interview with charge registered nurse (RN #1) was conducted. RN #1 reviewed Patient #9's medical record. RN #1 confirmed he was unable to locate any post discharge wound care instructions in the AVS.

On 6/4/19 at 3:42 p.m., an interview with a pediatric registered nurse (RN #3) was conducted. RN #3 stated it was important to provide written discharge instructions to patients so they had a reference when they returned home. RN #3 stated she knew what education needed to be included in the discharge instruction because physicians placed patient specific orders in the electronic health record (EHR). RN #3 stated she was also able to determine the information needed in discharge instructions by reviewing physician notes and the discharge summary. RN #3 stated a patient discharged with a wound should be provided information on how to clean the wound and prevent infection so the patient would not have to be readmitted to the hospital. RN #3 stated the patient with a wound should be provided with signs and symptoms to monitor for infection such as redness, drainage and swelling, as well as instructions not to submerge the wound in water until healed to prevent an infection. RN #3 stated if specific wound instructions were not included in the AVS there was no way to determine if instruction occurred.

b. According to Patient #3's Discharge Summary, he was discharged on [DATE] with a left occipital scalp laceration which was closed with staples. Physician orders were reviewed and revealed no specific wound care instructions. The AVS from 5/16/19 was reviewed and revealed Patient #3 was to follow up in the trauma clinic two weeks after discharge to have staples removed. Further review of the AVS showed no documented instructions were given to Patient #3 on how to care for the wound for the two weeks before the clinic visit.

On 6/4/19 at 12:38 p.m., an interview with RN #1 was conducted. According to the interview, RN #1 stated aftercare instructions were written by the physician and were required at the time of patient discharge so that the patient knew how to care for their wounds and who to call if they had questions. RN #1 stated the patient should receive written instructions so that the patient has something to refer to so they could remain safe after discharge. The instructions should include how to care for wounds, such as clean with soap and water but not to scrub the area. RN #1 stated the instructions should include: signs of infection the patient should monitor for, such as redness and/or drainage, a follow up appointment to remove the staples and a number to call with any questions. After reviewing the AVS, RN #1 stated there should have been some instructions how to care for the wound to prevent an infection and prevent a return to the hospital. RN #1 reviewed the record for Patient #3 and stated the discharging nurse documented she reviewed all the instructions on the AVS, but since there was no wound care instructions in the AVS, he couldn't confirm instructions were provided.

On 6/4/19 at 2:21 p.m., an interview with Care Management Manager (Manager) #2 was conducted. Manager #2 stated discharge planning was a multidisciplinary team approach. Manager #2 stated wound care orders and instructions were placed in the EHR by the patient's physician and reviewed by the RN with the patient. Manager #2 stated the AVS was what the patient received as printed discharge instructions and should reinforce the education the patient had received. Manager #2 stated patients should have instructions to refer to when at home to answer any post hospital questions and to ensure the patient remained safe at home.

On 6/4/19 at 1:22 p.m., the senior quality nurse (Quality RN #5) provided a draft of a policy which had not yet been approved which included the nursing guidelines to discharge a patient. Quality RN #5 stated there were no policies in effect at the time of the survey with nursing guidelines in regards to discharge.