F0627

D

Failure to Provide Wound Care Instructions and Supplies at Discharge

Mount Pleasant, Pennsylvania Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involved the facility’s failure to provide complete discharge information and necessary wound care supplies to a resident being discharged home. The facility’s discharge planning policy required development and implementation of a discharge plan that focused on the resident’s discharge goals, preparation for transition to post-discharge care, and reduction of preventable readmissions. The resident’s admission MDS showed the resident was cognitively intact, incontinent of bowel and bladder, and at risk for developing pressure ulcers, with no existing pressure ulcers at that time. On a later date, the resident developed full-thickness moisture-associated skin damage on the sacrum measuring 6.2 x 3.6 x 0.2 cm, and a physician’s order was initiated for daily cleansing of the sacrum with soap and water, patting dry, and application of Medi-honey once a day. The TAR documented that Medi-honey was applied on two consecutive days prior to discharge.

On the day of discharge, nursing documentation indicated the resident was discharged home, medications were reviewed with a family member, and discharge instructions were provided. However, the written discharge instructions, which indicated the resident was being discharged home with home health, did not reflect that the resident was receiving wound care, as the wound care section was marked “N/A.” The drug disposition form showed that medications were sent home with the resident, but there was no documentation that Medi-honey was provided. In an interview, the Nursing Home Administrator confirmed there was no documented evidence that the resident or family received Medi-honey or wound care instructions upon discharge, despite the active physician’s order for daily wound treatment to the sacrum.