Failure to Ensure Timely Pre-Operative Testing and Infection Management
Penalty
Summary
A resident with a history of right knee dislocation, type 2 diabetes, muscle weakness, and subsequent complications including right leg wound infection and nerve palsy, was admitted to the facility following acute care hospitalization. The resident had an external fixator device in place and was dependent on staff for activities of daily living and positioning. The care plan included monitoring for infection and circulation complications, but did not specify interventions for follow-up care related to the wound or removal of the fixator. Over several months, the resident required multiple antibiotics for ongoing right leg infections and developed additional pressure injuries around the fixator pin sites. The deficiency occurred when the facility failed to ensure timely completion of pre-operative testing, specifically a Venous Doppler, as ordered by the physician prior to the scheduled surgical removal of the external fixator. The Doppler was required to be completed 24 to 48 hours before surgery, but the order was entered and signed off as completed eight days prior, without verification that the test was actually performed. When the error was discovered, a STAT order was placed, but the test was not completed in time, resulting in the cancellation of the scheduled surgery. The resident missed multiple follow-up appointments with the orthopedic surgeon due to lack of transportation and coordination by the facility, and the surgery for device removal remained unscheduled at the time of the survey. Further contributing to the deficiency, the facility did not continue the resident's antibiotics after the surgery was canceled, despite ongoing infection and purulent drainage from the wound sites. The infectious disease and wound care providers were not informed of the lapse in antibiotic therapy, and a wound culture was never obtained as previously recommended. The attending physician was not notified of the surgery cancellation or the failure to complete the required pre-operative testing. These failures resulted in delays in necessary surgical intervention and ongoing management of the resident's infection.