Failure to Monitor and Assess Surgical Site Leading to Infection
Penalty
Summary
A deficiency occurred when a resident with a history of chronic pain, osteoarthritis, hemiplegia, and hemiparesis underwent a spinal cord stimulator implant and subsequently developed an infection at the surgical site. The resident's care plan included interventions for chronic pain and neuropathy, and a revision noted the potential for infection related to the back pain stimulator. However, there were no physician orders in the electronic medical record to monitor the surgical sites following the procedure, and documentation regarding the removal of staples and the healing status of the incisions was unclear. Staff interviews and record reviews revealed that the resident's surgical sites were not consistently assessed by the nurse practitioner (NP) or medical doctor (MD) to determine if they were healed. On one occasion, swelling at the incision sites was reported to a nurse, who assessed the area and notified the assistant director of nursing (ADON), but there was no documentation of this assessment or further notification to the NP. The following day, one of the incisions dehisced, resulting in bleeding and purulent drainage, and the resident was sent to the hospital where an infection was diagnosed. Multiple staff members, including the wound care nurse and NP, stated they were not notified of changes in the resident's condition, and there was confusion among staff regarding who was responsible for monitoring and assessing surgical wounds. The facility's policy required prompt notification of changes in a resident's condition to the attending physician, but this was not followed in the case of the resident's surgical site changes. Interviews indicated that nurses were unsure whether they could determine if a wound was healed, and the NP confirmed that only a physician or NP should make that determination. The lack of clear communication, documentation, and adherence to professional standards of practice led to a delay in identifying and treating the infection, resulting in hospitalization for the resident.