Failure to Communicate and Implement OT Referral After Orthopedic Surgery
Penalty
Summary
A facility failed to communicate and implement an Occupational Therapy (OT) referral ordered by an Orthopedic Surgeon for a resident who had undergone open reduction internal fixation (ORIF) surgery for a right olecranon fracture. The OT referral, which included instructions for range of motion (ROM), pain and edema control, a home exercise program, and splint removal for hygiene and active ROM, was not relayed to the therapy department. The referral order was scanned into the resident's electronic health record under a different tab from other orthopedic information, resulting in it not being reviewed or acted upon by nursing or therapy staff. The resident, who had severe cognitive impairment and required maximal assistance with upper body dressing and personal hygiene, did not have her splint removed or receive OT evaluation and treatment as ordered. The splint remained in place for nearly two months, and the resident was not evaluated by OT until over three months after the initial referral. During this period, the resident developed two pressure ulcers on the right elbow, one of which exposed surgical hardware and became infected, ultimately requiring surgical intervention for hardware removal and intravenous antibiotics for MRSA. Interviews with facility staff, including the DON, Therapy Director, and Medical Director, confirmed that the OT referral was not communicated or implemented due to breakdowns in the process for handling outside provider orders and documentation. The Orthopedic Surgeon and Therapy Director both stated that the resident should have received OT services as ordered, and the lack of therapy and splint removal contributed to the development of pressure wounds and infection. The deficiency affected one resident reviewed for therapy and resulted in significant harm.
Removal Plan
- Administrator and Director of Clinical Services reviewed all resident orders with outside appointments to ensure they were in place and correct.
- Therapy Director completed an audit of all current facility residents with therapy orders to ensure the correct physician ordered treatment was in place.
- Ad Hoc QAPI meeting conducted to review and determine root cause of the deficient practice.
- Education implemented on who will be responsible for ensuring the referral form is brought back to the facility when a resident has an outside appointment so new recommendations or orders can be implemented.
- Unit Manager will be responsible for ensuring the referral form returns with the resident; if it is the weekend or after hours, the hall nurse will be responsible.
- Transporter will notify the Unit Manager the resident is back from the appointment and will give her any paperwork at that time.
- If there is no referral form, the Unit Manager will call the physician office to obtain a copy of the form.
- Director of Clinical Services provided education to the Administrator, DON, Transportation driver and ADON on new procedures for handling outside appointment paperwork and therapy referrals.
- Unit manager, or designee, will be responsible for entering orders and ensuring any therapy referrals are received by therapy.
- DON will have a list of resident appointments and will follow up with the Unit Managers to ensure all referral forms have been returned and reviewed, with any new orders entered into the medical record.
- Nurse Aides that accompany a resident to an outside appointment are there to care for the resident; the Transportation Driver will be responsible for ensuring any paperwork, and the referral form, are returned to the Nurse Manager or hall Nurse.
- Unit Manager was educated that when a family member signs the resident out for an outside appointment, they are to follow up with the family when they sign the resident back into the facility to ensure all paperwork has been given to the nurse for review.
- Unit Managers, or designee, will be responsible for taking any therapy referral orders for new admissions to the therapy department on the day of admission.
- DON and ADON provided education to all facility Licensed Nurses and Nurse Aides on new procedures for handling outside appointment paperwork and therapy referrals.
- Current facility Licensed Nurses and newly hired nurses not received education will not be allowed to work until the education has been completed.
- DON will utilize an active employee list to track completion of education and validate the post education written test was completed and passed.
- Education will also be included during orientation for newly hired facility Licensed Nurses, Nurse Aides, and Transportation drivers, to be completed by Director of Nursing or Nurse Manager.
- Administrator and Director of Nursing will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged noncompliance.