Failure to Ensure Resident Wore Cranial Helmet as Ordered
Penalty
Summary
The facility failed to ensure that a resident who had undergone a craniotomy consistently wore a cranial helmet as ordered by the physician. Observations revealed that the resident was not wearing the helmet on multiple occasions, and both a CNA and an LVN were unable to locate the helmet or determine how long it had been missing. The resident's care plan and physician orders specified that the helmet should be worn at all times except during showers, but staff interviews confirmed that this was not being followed. The resident had severe cognitive impairment, was dependent on staff for activities of daily living, and had a history of behaviors such as removing the helmet and picking at the surgical site. Record reviews indicated that the resident had a surgical incision with staples on the head and had experienced episodes of wound dehiscence and infection, requiring antibiotics and wound care. Staff interviews further revealed a lack of communication and follow-up with the resident's physician regarding the care plan and orders. The failure to ensure the resident wore the cranial helmet as ordered placed the resident at risk for further injury and delayed healing, as directly noted in the report.