Failure to Assess Change in Condition and Follow Provider Orders After Surgery
Penalty
Summary
A deficiency occurred when the facility failed to adequately assess a resident and follow provider orders after a change in condition following hip surgery. The resident, who had a history of left femur fracture, type 2 diabetes mellitus, and dementia, returned to the facility after surgical intervention for a hip fracture. On a specific date, the resident's leg was observed to be red, swollen, and warm, prompting a nurse practitioner to order a doppler ultrasound to rule out a blood clot. However, there was no evidence that this order was entered into the resident's medical record or the treatment administration record, nor was it referenced in progress or therapy notes in the days following the order. Despite the resident continuing to exhibit symptoms such as swelling, redness, and pain in the left leg over several days, there was no documentation of ongoing assessment, vital signs, or pedal pulse checks in the progress notes. The doppler ultrasound order was not processed in a timely manner, with delays in both entering the order into the resident's chart and submitting the request to the mobile ultrasound company. Staff interviews revealed confusion about the process for submitting urgent orders and uncertainty about the availability of the mobile ultrasound service on weekends. Communication lapses occurred, as nurses did not update the nurse practitioner about the resident's status or the lack of completion of the doppler study. The resident's condition deteriorated, and several days after the initial change in condition, the leg was found to be cold, deeply discolored, and pulseless. The resident was then sent to the hospital, where extensive blood clots were confirmed, and the resident was determined not to be a surgical candidate. The resident was admitted to inpatient hospice and subsequently passed away. The facility's failure to assess the resident's change in condition, document findings, and ensure timely completion of the ordered doppler study constituted the deficiency.