Mahaska Health Partnership

“DISCHARGE PLANNING CFR(s): (b) Standard: Discharge of the patient and provision and transmission of the patient’s necessary medical information. The CAH must discharge the patient, and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, postdischarge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 49842 Based on a review of patient medical records, hospital policies and procedures, staff interviews, and observations, the Critical Access Hospital (CAH)’s administrative staff failed to ensure inpatient nursing staff provided necessary written wound care instructions upon discharge for 1 of 10 sampled patients (Patient #3), despite the patient having an active pressure ulcer at the time of discharge. Failure to provide appropriate wound care guidance and instruction upon discharge placed Patient #3 (P3) at an increased risk of wound deterioration and infection and could have contributed to delayed healing. Findings include: 1. Review of the hospital’s 6/2025 policy “Nurses’ Role in Discharge Planning” revealed in part: a. “ ...The patient (or legal representative) will be provided the opportunity to designate or decline a lay caregiver at the time of admission and again at discharge as required by the Iowa CARE Act.” b. “Definitions for the purpose of this policy:” i. “Patient: individual who is receiving or who has received inpatient medical care in a hospital.” ii. “Lay caregiver: individual, eighteen years of age or older, who is designated as a lay caregiver by a patient or the patient’s legal representative, and who is willing and able to perform aftercare assistance for the patient at the patient’s residence (home) following discharge (the exit or release of a patient from inpatient care in a hospital to the residence of the patient)”. iii. “Aftercare assistance: any assistance provided by a lay caregiver to a patient following discharge of the patient that are tasks related to the patient’s condition at the time of discharge, do not require a licensed professional, and are determined to be appropriate by the patient’s discharging physician or other licensed health care professional.” c. “Procedure” i. The hospital shall attempt to notify the caregiver of the discharge. ii. Consult with the patient’s lay caregiver to prepare him/her for aftercare assistance. iii. Issue a discharge plan that describes the aftercare assistance tasks described in the discharge plan and allow the lay caregiver to ask questions regarding such tasks. d. The hospital staff will complete the following when the patient is discharged: i. Written instructions will be given to the patient family/support person and/or lay caregiver who verbalize/demonstrates good understanding with teach back methodologies. ii. Discharge arrangements/referrals are completed and documented in the record and discharge instruction sheet. iii. All identified “needs” of the patient have been dealt with. iv. Discharge Nursing Assessment is completed. 2. Review of Patient #3 (P3)’s medical record revealed the following: a. On 3/5/26 at 1:49 PM, P3 presented to the Emergency Department (ED) via ambulance with a chief complaint of nausea, vomiting, and headaches with a history of flaccid quadriplegia (a severe neurological condition involving loss of motor control in all four limbs), completely dependent on a full-time caregiver at home. Staff K (Registered Nurse (RN)) triaged P3 and documented foul-smelling, bloody drainage from the suprapubic catheter insertion site. b. On 3/5/26 at 1:49 PM, Staff A (ED Provider) completed an assessment of P3 and noted P3 was experiencing tachycardia, dry mucous membranes, and abdominal tenderness. Staff A (ED Provider) also evaluated a pressure ulcer located on P3’s coccyx and subsequently ordered a wound culture of the coccyx and the suprapubic catheter insertion site. c. On 3/5/26 at 4:10 PM, Staff A documented laboratory results from a respiratory panel revealed a positive Respiratory Syncytial Virus (RSV) test, and a urinalysis was positive for a Urinary Tract Infection (UTI). d. On 3/5/26 at 4:12 PM, Staff A (ED Provider) ordered a fluid bolus due to hypotension (low blood pressure). e. On 3/5/26 at 6:47 PM, Staff A (ED Provider) consulted with Staff B (Hospitalist) to evaluate appropriateness for inpatient admission, given P3’s history of complicated UTIs and sepsis. At 7:15 PM, P3 was admitted to an inpatient bed. f. On March 5, 2026 at 7:13 PM, Staff B (Hospitalist) performed an evaluation of P3 for inpatient admission. Staff B documented P3’s history of multiple multidrug-resistant UTIs and noted the patient’s most recent urine culture was sensitive to Rocephin. (a broad-spectrum antibiotic used to treat serious bacterial infections) Subsequently, Staff B ordered Rocephin 2 grams (g) to be administered intravenously (IV) and initiated a consultation with urology. A wound care consultation was also ordered for the following morning. Additionally, Staff B observed that P3 was experiencing constipation and noted the patient had not been compliant with the ordered home regimen for constipation, which included Lactulose 20 g three times a day and Miralax 17 g two times a day. g. On March 6, 2026 at 11:34 AM, Staff F (Advanced Registered Nurse Practitioner (ARNP)) conducted a wound consultation. The consultation documented P3 reporting the development of new wounds on his toes subsequent to his feet becoming entangled in the wheelchair. Staff F observed a stage 1 pressure ulcer on the right buttock, which measured 0.9 centimeters (cm) in length, 0.1 cm in width, and 1 cm in depth. Furthermore, a stage 2 pressure ulcer was noted on the left buttock, measuring 1 cm in width, 1 cm in length, and 1 cm in depth. Staff F’s assessment indicated both wounds exhibited granulation tissue with no active drainage, tunneling, or undermining present. Staff F also noted a cluster of blisters to the right thigh, measuring approximately 1 cm, with no signs of infection. h. On March 6, 2026 at 11:34 AM, Staff F (ARNP) documented orders for P3, instructing staff on the consistent utilization of heel boots for the protection of the toes and heels. The orders further delineated the application of a thick layer of Triad Hydrophilic Wound Dressing (sterile, zinc-based paste for chronic wounds that facilitates autolytic debridement) to the buttock three times per day and as needed (PRN). Additional interventions stipulated the provision of a pressure redistribution mattress, the use of a waffle cushion upon transfer to a chair, and turning and repositioning of the patient every three hours with a pillow positioned under the buttocks. i. Concurrently, on March 6, 2026 at 11:34 AM, Staff F (ARNP) directed nursing personnel to cleanse the site of the suprapubic catheter with mild soap and water, followed by the application of a drain sponge daily. Staff F also instructed nursing personnel to apply an Optifoam (5-layer bordered foam dressing) to the blisters located on P3’s right thigh with orders to change weekly. j. On 3/13/26 at 11:26 AM, Staff F (ARNP) documented a wound assessment of P3 with no change in the orders for wound care for the pressure ulcers on the coccyx, the suprapubic catheter insertion site, or the clump of blisters on the right thigh. k. On 3/14/26 at 1:52 PM, P3 was discharged home. Staff L (RN) initiated the discharge process at 1:20 PM, which included arranging emergency medical services (EMS) transport and printing discharge instructions. Staff L (RN) then provided a handoff report for P3 to Staff G (RN), who subsequently reviewed the discharge instructions with P3 and documented the caregiver (significant other) received a copy of the instructions; however, staff failed to include wound care instructions for pressure ulcers, the suprapubic catheter insertion site, or blisters on the right thigh in the After Visit Summary (AVS) or discharge instructions and failed to document evidence of reviewing said instructions with the patient’s full-time caregiver prior to discharge. P3 was subsequently transported home via EMS. 3. During an interview on 4/20/26 at 3:30 PM, Staff H (RN) reported that prior to P3’s discharge, there were no wound care orders available for printing on the After Visit Summary (AVS). Staff H reported they attempted to call the significant other for P3, who is also the full-time caregiver, following the patient’s discharge, but did not get an answer. Staff H reported reviewing wound care notes in the medical record and printing off some of the notes for the discharge packet to provide instructions for the caregiver. 4. During an interview on 4/21/26 at 10:00 AM, Staff G (RN) reported reviewing the discharge instructions with P3 prior to transport home; however, Staff G could not recall if wound care instructions were included in the discharge packet. 5. During an interview conducted on 4/21/26 at 10:45 AM, Staff F (ARNP/Wound Care Team) stated the patient’s discharge date had not been communicated to the Wound Care Team. Consequently, Staff F was unaware that P3 would be discharged home over the weekend and therefore did not enter specific wound care instructions into the Electronic Medical Record for the patient’s home environment. 6. During an interview on 4/21/26 at 3:30 PM, Staff J (Director of Inpatient Care) acknowledged the wound care instructions did not print off with the AVS and could not verify what was specifically sent home with P3 at discharge from the medical record.”