Failure to Follow Physician Orders for Surgical Wound Care
Penalty
Summary
Facility staff failed to follow physician orders regarding the removal of surgical staples for a resident who had undergone a C2-T10 posterior spinal fusion and T4 corpectomy. The hospital's transfer orders specified that the staples should be removed three weeks postoperatively unless there were concerns about the incision, in which case the surgeon should be contacted. Review of the resident's electronic medical record showed no documentation that the staples were removed or that the surgeon was contacted regarding the incision. Additionally, when the resident was discharged to their prior living facility, there was no documentation sent regarding the presence of staples in the incision or instructions for their removal. Staff interviews confirmed that the order for staple removal was missed and that this information was not communicated to the receiving facility. This lapse was identified during record review and staff interviews, with no evidence that the required care was provided or communicated.