F0627

D

Failure to Provide Complete Instructions, Medications, and Wound Care Preparation at Discharge

Lynnwood, Washington Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe and adequately prepared discharge for a resident with multiple medical needs. The resident was admitted with diagnoses including diabetes, a right foot wound, and depression, and had moderate cognitive impairment per the Minimum Data Set. The resident was discharged home with family, but review of the electronic health record showed the discharge instructions and discharge summary were incomplete. The discharge packet did not contain discharge instructions, a discharge summary, or physician orders for wound care to the resident’s right foot. There was no documentation that wound care training had been provided to the resident or family prior to discharge.

Further review of the resident’s records showed that the document titled “Medications discharged with Resident” did not list blood pressure, antidepressant, or insulin medications. The discharge packet also lacked documentation that wound care supplies, blood pressure medication, antidepressants, and insulin were sent with the resident. In interviews, the resident’s family contact stated they were not educated on wound care and did not receive wound care supplies or insulin. Social services staff and the nurse manager acknowledged that the discharge instructions and summary were incomplete and that there were no wound care orders, no documentation of wound care training, and no documentation of the necessary medications being provided at discharge. The DON confirmed that the discharge packet was missing the required discharge documents, medication listings, wound care orders, and documentation of wound care supplies and training, despite facility expectations that discharged residents receive these items.