Failure to Follow Post-Hospitalization Care Instructions
Penalty
Summary
The facility failed to provide appropriate care and services for a resident, identified as Resident R68, following their hospitalization. The resident was admitted with diagnoses including anemia, chronic kidney disease, and osteomyelitis. Hospital discharge instructions specified that the dressing on the resident's right lower extremity should only be reinforced and not changed until a follow-up appointment. However, a progress note indicated that the dressing was changed without an order, and a soiled bandage was used to wrap the wound, which was against the physician's instructions. Staff interviews revealed that the dressing was removed and replaced with a dirty ace wrap, despite orders to only reinforce the dressing and notify the doctor in case of excessive drainage. The Unit Manager and Nursing Home Administrator confirmed that the dressing was changed without an order, and the facility failed to provide the necessary care and services for the resident after hospitalization. This incident highlights a deficiency in adhering to professional standards of practice and the resident's care plan.
Plan Of Correction
Immediate Intervention: Surgeon was notified that dressing was removed. Orders received from surgeon for dressing. Immediate education for all nurses involved in dressing change was given. Education on following doctor's orders. How to Identify residents who can be affected: All residents can potentially be affected. Prevention of further occurrence: Immediate education for all nurses was started. All nursing staff will be trained in following doctors' orders using policy 7.1 medication administration. Corrective Action to monitor: Audit tool created to review staff compliance to review physician orders against completion. The wound nurse or designee will audit new wounds five days a week for three weeks, weekly for three weeks, and monthly for three months. QA Program: Identification of staff noncompliance will result in a performance improvement plan with potential for corrective action and discipline. Treatment compliance added to monthly QAPI for review.