Failure to Notify Physician of Change in Condition Following Surgical Procedure
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's condition, specifically regarding swelling and tenderness at surgical incision sites. The resident, a cognitively intact male with chronic pain, osteoarthritis, hemiplegia, and hemiparesis, had recently undergone a spinal cord stimulator implant. Despite documented interventions in the care plan to notify the physician as needed for potential infections, there were no physician orders to monitor the surgical sites, and staff did not communicate changes in the resident's condition to the nurse practitioner (NP) or wound care nurse (WCN) when swelling and tenderness were observed. On the day prior to the resident's hospitalization, a CNA observed swelling at the incision sites and reported it to an LVN, who assessed the sites and notified the ADON. However, the NP and WCN were not informed of these changes. The following day, the resident's incision dehisced, with drainage of blood and pus, prompting transfer to the hospital where an infection was diagnosed. Interviews with staff revealed a lack of clarity regarding responsibility for monitoring and reporting changes in surgical sites, and some staff were unaware of the need to notify the NP or WCN of such changes. Documentation and communication lapses were evident, as the NP stated she was not notified of the swelling and would have taken immediate action if she had been informed. The facility's policy required prompt notification of the physician for changes in a resident's condition, but this was not followed in this case. The deficiency was identified as Immediate Jeopardy due to the failure to ensure timely physician notification and appropriate monitoring of the resident's surgical sites, which resulted in the resident developing an infection that required hospitalization.