Failure to Inform Responsible Party and Provide Wound Care Instructions at Discharge
Penalty
Summary
The facility failed to implement an effective discharge plan for a resident with significant medical needs, specifically by not informing the responsible party of a pressure wound and not providing wound care instructions prior to discharge. The resident was admitted with multiple complex diagnoses, including a femur fracture, multiple myeloma, COVID-19, pneumonia, and encephalopathy, and was noted to have Stage 2 pressure ulcers on admission. Over the course of the stay, the resident developed an unstageable deep tissue injury to the right buttock, which was later debrided and identified as a Stage 4 pressure ulcer on the day of discharge. Despite the presence of this severe wound, there was no documentation that the responsible party was notified about the wound or the need for daily wound care. Interviews with nursing staff, the wound care physician, and the social worker confirmed that the responsible party was not informed of the wound or provided with wound care instructions. The discharge paperwork prepared by the social worker did not include information about the wound or required treatments, and the nurse who discharged the resident did not discuss the wound care needs with the responsible party, as this information was not present on the discharge form. The lack of communication and coordination among the interdisciplinary team resulted in the responsible party being unaware of the resident's wound and the necessary care required at home. The responsible party only became aware of the wound after discharge, when they contacted the facility with concerns. Documentation and interviews confirmed that the wound and its care requirements were not reviewed with the responsible party prior to the resident's discharge.