Failure to Obtain and Implement Physician Orders for Post-Operative Wound Care
Penalty
Summary
The facility failed to obtain and implement physician orders for the care of a post-operative surgical wound for one resident, resulting in significant complications. Upon admission, the resident had a recent abdominal surgery with staples in place and was experiencing severe, nearly constant pain. The hospital discharge instructions indicated that staples were to be removed on post-operative day ten, but did not provide specific instructions for wound assessment, care, documentation, or criteria for physician notification. Facility documentation and care plans lacked any plan of care or interventions for the surgical wound, and there were no orders or documentation related to wound care, assessment, or monitoring for complications. Nursing staff did not perform or document appropriate wound assessments or dressing changes during the initial days following admission. The resident's pain was not effectively managed, and staff failed to notify a physician or seek further guidance despite the presence of significant drainage and an unhealed incision. The wound was not assessed by an RN, and the LPN who provided care did not contact the on-call provider. When the staples were eventually removed, the wound dehisced, leading to rehospitalization and emergency surgery. Interviews with staff revealed a lack of clarity regarding responsibilities for wound care and assessment, and a reliance on incomplete or absent orders from the hospital. The resident's family reported concerns about uncontrolled pain and saturated dressings, and staff interviews confirmed that wound assessments were not performed as required. The treatment nurse removed the staples based solely on the discharge paperwork, without confirming the wound's readiness or consulting the surgeon or provider. The lack of a coordinated approach to wound care, absence of physician orders, and failure to document or communicate changes in the resident's condition directly contributed to the resident's wound dehiscence and subsequent complications.