Delay in Implementing Hospital Discharge Wound Care Orders
Penalty
Summary
A resident with severe cognitive impairment and multiple diagnoses, including adult failure to thrive and chronic low back pain, experienced an unwitnessed fall resulting in a head laceration. The resident was transferred to the emergency room, where the laceration was repaired with staples. Upon discharge, the hospital provided instructions to wash the wound and apply Neosporin or bacitracin ointment. However, upon the resident's return to the facility, these wound care instructions were not implemented immediately. The medical record and staff interviews confirmed that the order to apply Neosporin or bacitracin was not obtained or started until two days after the resident's return, following a fax to the provider for clarification. There was no documentation that the ER discharge orders were reviewed upon the resident's return, and the Director of Nursing was unable to explain why the wound care was not initiated as directed. As a result, the resident did not receive the prescribed wound care treatment according to the hospital's discharge instructions.