Failure to Obtain Timely Physician Order for Staple Removal After Fall
Penalty
Summary
A resident with dementia, a history of falls, and severely impaired cognition experienced an unwitnessed fall resulting in a scalp laceration. The resident was transferred to the emergency department, where the laceration was treated with five staples. Upon return to the facility, a physician's order was entered to monitor the staples and report any signs of infection or bleeding, but the order did not specify a stop date or include instructions for staple removal. The omission of a stop date and removal instructions was not identified during routine chart checks by nursing staff, as required by facility policy. As a result, the staples remained in place for 13 days, exceeding the typical duration for such wound closures. The facility's documentation and interviews revealed that the responsible nurse was unaware of the missing stop date and had not received education on the incident. Additionally, the facility was unable to provide evidence of education or disciplinary action related to the failure to ensure timely staple removal. Facility policies required orders to include start and stop dates and for nurses to reconcile and verify orders upon a resident's return from another care setting, but these procedures were not followed in this case.