Failure to Monitor and Document Hemovac Drain Output per Professional Standards
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in the care of a resident with a Hemovac drain following spinal surgery. Upon admission, documentation noted the presence of a surgical dressing and Hemovac drain with serosanguineous drainage, but there was no evidence that the output from the drain was measured or recorded according to facility policy, which requires emptying and measuring every 4 to 8 hours. Review of the resident's medical record revealed a lack of physician orders for monitoring, emptying, or documenting the Hemovac drain's function and output during the resident's stay. Staff interviews confirmed that there was no documentation or recollection of orders related to the drain, and the Assistant Director of Nursing and Director of Nursing were unable to provide evidence of required monitoring or orders for the drain during the relevant period. Further, during a follow-up appointment, the facility was unable to provide documentation of the Hemovac drain's output to the surgeon's physician assistant, who expected at least twice-daily monitoring and documentation. The facility physician also stated that standard practice includes having orders to monitor drainage, ensure proper function, and observe for infection. The lack of documentation and physician orders for the Hemovac drain's management, as well as the absence of output monitoring, constituted a failure to meet professional standards of quality for this resident.