Failure to Implement and Document Grievance Resolution for Timely Staple Removal
Penalty
Summary
A deficiency occurred when the facility failed to implement and document the resolution of a grievance related to the timely removal of scalp staples for a resident with dementia, a history of falls, and anxiety disorder. The resident experienced an unwitnessed fall resulting in a scalp laceration, which was treated in the emergency department with five staples and an order for antibiotic therapy. Upon return to the facility, a physician's order was entered to monitor the staples and report any signs of infection, but the order did not specify a stop date or a timeline for staple removal. The staples remained in place beyond the expected timeframe, and the omission was not identified or corrected until a grievance was filed by the resident's family member. The facility's grievance investigation revealed that the nurse responsible for entering the physician's order did not include a stop date for staple removal and was not educated on the incident. Interviews with staff indicated that the education of the nurse, which was listed as a corrective action in the grievance resolution, was neither documented nor completed. The facility was unable to provide evidence of the required education or disciplinary action, and the grievance form was found to be incomplete and inaccurate, contrary to facility policy.