Failure to Follow Physician Orders and Infection Control for Surgical Site
Penalty
Summary
The facility failed to follow physician admission orders and provide appropriate care for a resident who was admitted after a cerebral vascular accident and craniectomy. The resident had specific physician orders for daily skin checks, use of antiseptic/disinfectant shampoo on the surgical site, wearing a cranium helmet when out of bed, and craniectomy precautions. Upon review, there was no documentation that these orders were implemented. The resident's admission assessment did not note the surgical site, helmet use, or required isolation precautions. The Medication Administration Record and Treatment Administration Record did not include the necessary orders for daily skin checks, helmet use, or antiseptic shampoo. Staff interviews confirmed that the resident was not receiving the ordered care, and the surgical site was not being monitored or cleaned as directed. Observations revealed that the resident's room lacked signage for Enhanced Barrier Precautions (EBP), and there was no accessible personal protective equipment (PPE) or designated disposal bins. Staff, including LPNs and CNAs, were observed providing care and handling the resident's helmet and surgical site without wearing appropriate PPE or following EBP protocols. The resident's helmet, which had openings exposing the scalp, was handled with bare hands, and the surgical site was left uncovered and draining. Staff were unaware of the need for antiseptic shampoo and used standard facility soap instead. There was no communication or documentation of changes in the surgical site, and staff did not report redness or drainage to nursing or medical staff. Family members and medical professionals expressed concerns that the lack of adherence to physician orders and failure to monitor and care for the surgical site led to the development of a Methicillin Susceptible Staphylococcus Aureus (MSSA) infection. This infection required additional medical interventions, including antibiotics, a second hospitalization, and surgical debridement of the scalp. Facility leadership acknowledged that the required orders were not implemented, the surgical site was not assessed or monitored, and EBP was not initiated upon admission. The facility also lacked a wound care program for non-pressure-related wounds, contributing to the failure to provide appropriate care for the resident's surgical site.