Failure to Provide Discharge Instructions for Surgical Wound Care
Penalty
Summary
A deficiency occurred when a resident who had an orthopedic consultation with an order for a daily dry dressing change to the right hip was discharged from the facility without receiving the necessary wound care instructions. The discharge instructions provided to the resident and their representative did not include information about the required daily surgical wound dressing change. The resident was independent in decision-making at the time of discharge. Interviews revealed that the DON acknowledged an oversight in not entering the order for the daily dressing change, and the nurse responsible for the discharge was unaware of the order and did not communicate the need for surgical dressing changes to the resident or their representative. When the home health nurse visited the resident after discharge, she found no instructions for the surgical wound dressing changes in the facility's referral orders and had to perform the dressing change herself.