Failure to Ensure Appropriate Discharge and Accurate Wound Information
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was discharged to a setting capable of meeting the resident’s wound care needs and to accurately communicate the presence and status of a significant pressure injury at discharge. The resident was admitted with an unstageable right heel pressure ulcer/diabetic foot ulcer and had ongoing daily wound care with povidone-iodine and dressings. A wound assessment completed six days prior to discharge documented a non-healable right heel diabetic ulcer with 100% eschar, negative progression, additional devitalized tissue, and daily Betadine treatment. Despite this, the physician’s 602 form completed earlier indicated “R heel w/o pressure injury,” and the nurse practitioner later confirmed that “w/o” meant “without,” while being unable to recall why the heel was documented as without a pressure injury. The case manager confirmed that the 602 form, which indicated no pressure injury, was emailed to the assisted living facility (ALF) prior to discharge. The ALF’s Resident Service Director reported that their Executive Director had visited the SNF and saw the resident’s heel covered with a dressing; SNF staff reported the wound was healing, and the 602 form signed by the nurse practitioner indicated no pressure injury. The ALF typically relies on such information to determine whether a resident is appropriate for admission and generally can accept only simple wounds, not unstageable wounds. The social services director stated that usually the ALF determines if a resident is appropriate and that ALFs typically do not take unstageable wounds. On the day of discharge, the order summary documented that the resident requested discharge to the ALF with home health nursing, PT, and wound care, and included specific wound care orders for the right heel diabetic foot ulcer, including Betadine application and dressing instructions. However, the registered nurse confirmed that the Discharge Instruction Form/Recapitulation of Stay listed discharge to a private residence and did not document the right heel wound. Upon admission to the ALF, staff assessed the right heel wound as unstageable and, due to their inability to care for it, transferred the resident to a general acute care hospital the same day. These actions and documentation discrepancies show the facility did not ensure the discharge destination could meet the resident’s care needs and did not provide accurate, complete wound information in the discharge documentation sent to the receiving facility.
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