Failure to Assess and Implement Post-Operative Wound Care Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident admitted with a post-operative surgical wound on the neck following an anterior cervical discectomy and fusion (ACDF) procedure. Upon admission, the resident had a dressing in place with instructions from the hospital to leave the dressing until a specified date, then either leave the incision open to air or cover with sterile gauze for comfort, and to monitor daily for signs of infection. However, the facility did not obtain or implement specific physician orders for the surgical wound care as outlined in the hospital discharge instructions. Multiple staff members, including nurses and the wound nurse, did not assess the surgical incision site as required. The admitting nurse did not complete the required Nursing Advantage Clinical Admission Assessment, which included a skin assessment, and did not extract or submit the hospital's wound care instructions for physician orders. Nursing documentation over several days failed to consistently assess or document the condition of the surgical wound, and the wound was not examined by the physician or nurse practitioner during their assessments. Some staff reported not removing the resident's soft collar or dressing to assess the wound, citing either lack of permission or misunderstanding of instructions. Interviews with staff revealed a lack of clarity and communication regarding the care and assessment of the surgical wound. The wound nurse was not alerted to drainage from the incision, and the staff relied on verbal reports rather than reviewing the clinical record for wound care instructions. The resident's surgical wound was not properly assessed for characteristics such as size, drainage, or signs of infection, and the required documentation and physician orders for wound care were not obtained or implemented, resulting in a failure to follow professional standards and the facility's own protocols.