Failure to Assess and Communicate Post-Surgical Site Care Leading to Pressure Injury
Penalty
Summary
A resident with severe cognitive impairment, non-traumatic brain dysfunction, hypertension, and Alzheimer's disease experienced an unwitnessed fall resulting in a right elbow fracture. Following an open reduction internal fixation (ORIF) surgical procedure, the resident returned to the facility with specific post-operative instructions, including non-weight bearing status, pain management, and incision care. The discharge instructions also required follow-up with an orthopedic specialist and outlined care for the surgical site, including keeping the splint dry and monitoring for drainage. Despite these instructions, there were no documented nursing assessments of the surgical site from the time of surgery through the next scheduled follow-up appointment. At a follow-up appointment with the orthopedic surgeon, new orders were given for occupational therapy (OT) to address range of motion, pain, edema control, and splint management, including removal for hygiene and active ROM exercises. However, this order was not processed or communicated to the OT department, and the resident did not receive the prescribed therapy. Additionally, the facility failed to document any nursing assessments of the surgical site or the resident's condition related to the splint and wound care for an extended period. The resident's next follow-up appointment was delayed due to illness, and the facility did not seek further guidance from the orthopedic surgeon during this delay. When the resident was finally seen again by the orthopedic surgeon, the splint was removed, revealing a pressure wound over the medial aspect of the elbow, limited range of motion, and retained steri-strips from the previous visit. The wound was later identified as a medical device-related stage 4 pressure injury with exposed hardware, which continued to deteriorate and ultimately required emergent surgery for irrigation, debridement, and hardware removal. Throughout this period, there was a lack of documented assessments and communication regarding the resident's surgical site, therapy needs, and wound care, directly contributing to the development and worsening of the pressure injury.