Failure to Assess and Document Cast Care Leading to Delayed Identification of Complications
Penalty
Summary
The facility failed to implement and document appropriate interventions for the assessment and care of a non-removable lower extremity cast for one resident. According to the facility's Cast Care policy, staff are required to assess the cast every shift for tightness, circulation, motion, sensation, drainage, odor, and skin irritation, and to document these assessments and report abnormal findings to a physician. After the resident was readmitted from the hospital, there were no orders in place for cast care, and staff did not obtain new orders or continue previous ones. The resident's Treatment Administration Record previously included orders to check circulation, movement, sensation, and temperature (CMST) every shift, but these were discontinued upon readmission, and no new orders were obtained. The resident subsequently reported increased pain in the right lower extremity, and it was noted that the cast was damp and had an odor. Staff did not perform or document regular cast assessments as required, and the wound nurse only became aware of the lack of cast care orders after being informed of a wound inside the cast. The orthopedic evaluation later identified increased pain, a wet splint, concerns for neurovascular compromise, infected pressure ulcers, and sepsis. Staff interviews confirmed that regular assessments were not performed and that the wound could have been identified sooner if proper procedures had been followed.