Failure to Provide Wound Care Education and Home Health Coordination at Discharge
Penalty
Summary
The facility failed to ensure that discharge planning needs were met for a resident with significant medical needs, specifically regarding wound care. The resident, who had quadriplegia and was unable to perform self-care for a stage 4 pressure wound on the coccyx, was discharged without adequate instruction or education provided to his caregiver on how to perform wound care as ordered by the physician. Documentation did not indicate that the caregiver received wound care education, nor was there evidence of a return demonstration to confirm competency. The discharge summary also lacked instructions on wound care and did not mention the presence of the stage 4 wound. Additionally, the resident was discharged without arrangements for home health services, which would have included nursing support for wound care, assessments, and education. Although the discharge planning care plan indicated that the resident would be assessed for discharge needs and provided with education, there was no documentation that home health services were offered or coordinated. The social services documentation noted that the resident would need to follow up with a primary care physician but did not include referrals for home health or information on obtaining wound care supplies. Interviews with staff confirmed that the resident was unable to perform his own wound care and that the caregiver should have received education, which was not documented. The resident and caregiver both reported not receiving wound care instructions or supplies at discharge, and the resident subsequently required multiple emergency room visits due to wound complications. The facility's failure to provide necessary education and coordinate post-discharge care did not meet the resident's needs or preferences for a safe and effective discharge.