Failure to Address Resident's Repeated Tampering with Surgical Drainage Tube
Penalty
Summary
The facility failed to provide appropriate care and services for a resident admitted after a cholecystectomy with a surgical drainage tube in place. The facility was unaware of the date of the resident's surgery and did not have information regarding necessary follow-up visits or treatments from the resident's surgeon. There was no documentation of the facility seeking this information from the hospital, family, or other sources, and the care plan did not address the resident's previously identified behavior of attempting to pull out the drainage tube. Multiple nursing notes documented that the resident had a history of pulling on the drainage tube, including specific incidents where the resident was observed attempting to remove it. Despite this, there were no interventions or care plan updates to address this behavior, and the physician was not notified of these incidents. Staff interviews confirmed that the resident frequently tampered with the tube and that this was a known issue upon admission, but no formal documentation or care planning was completed to mitigate the risk. Ultimately, the resident pulled out the drainage tube, resulting in redness and edema at the site, and was transferred to the hospital. The facility's own policies required prompt notification of changes in condition, comprehensive care planning, and measures to ensure resident safety and supervision, but these were not followed in this case. The lack of care planning, physician notification, and follow-up on the surgical procedure directly contributed to the deficient practice.