Failure to Coordinate Care, Monitor for Bruising, and Ensure Timely Wound Management
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs, resulting in missed medical appointments, delayed wound care, and inadequate monitoring for signs of bleeding or bruising. One resident with a non-chronic pressure ulcer of the left heel and a history of surgical aftercare missed a scheduled wound care clinic appointment because the facility did not arrange transportation, despite clear documentation that a follow-up was required. The resident confirmed missing the appointment, and the DON acknowledged the lapse in scheduling. Another resident with peripheral vascular disease, a history of thrombus/embolism, and chronic pain syndrome was prescribed an antiplatelet medication with orders to monitor for bleeding and bruising. Despite documentation in the treatment administration record indicating no signs of bleeding or bruising, direct observation and interviews revealed multiple bruises on the resident's hands that had not been previously identified or monitored by staff. The DON and Administrator confirmed that the monitoring documented in the record did not reflect the resident's actual condition, as reported by the resident and her family. A third resident, admitted after abdominal surgery with staples in place, experienced a delay in staple removal. Although the staples were to be removed seven to ten days post-surgery, they remained in place for over four weeks. The resident expressed concern about the prolonged presence of staples, and both the DON and a nurse practitioner confirmed the delay, with the nurse practitioner indicating a lack of clarity regarding follow-up appointments for staple removal. No physician order for staple removal was present until well after the recommended timeframe.