Failure to Provide Accurate Discharge Medication List and Wound Care Instructions
Penalty
Summary
The facility failed to provide an accurate and comprehensive medication list, including both prescription and over-the-counter medications, at the time of discharge for a resident with multiple diagnoses, including a stage 3 pressure ulcer. The discharge process did not include clear or complete wound care instructions, and the instructions that were provided were written in medical terminology that was not understandable to the resident's family member. The family member did not receive verbal instructions or a prescription for the necessary wound care supplies, and the written instructions did not specify wound care in a way that could be easily followed. As a result, the resident did not receive the prescribed wound care treatment for six days after discharge, until a home health nurse intervened. Review of the facility's records and interviews with the Director of Nursing confirmed that wound care instructions were not included in the appropriate discharge documents and that there was no documentation of wound care education being provided to the resident prior to discharge. The facility's policy required a post-discharge plan to be developed and reviewed with the resident or family, but this was not completed as required.