Failure to Follow Physician Orders for Post-Op Shoe After Toe Amputation
Penalty
Summary
A deficiency occurred when the facility failed to ensure physician orders were followed for a resident who had recently undergone a right great toe amputation. The resident, who had severely impaired cognition and a history of physical and verbal behavioral symptoms, returned from surgery with post-operative instructions that included weight bearing as tolerated in a post-op shoe to protect the surgical site. However, the post-op shoe was not included in the resident's care plan or the nursing assistant care plan, and staff were unclear about when and how the shoe should be used. Multiple observations showed the resident without the post-op shoe on the right foot, and at times, the shoe was incorrectly placed on the left foot instead. Interviews with staff revealed confusion and lack of knowledge regarding the post-op shoe order, with some staff believing the shoe should not be used or not knowing which foot it belonged on. The resident's medical history included non-traumatic brain dysfunction, peripheral vascular disease, diabetes mellitus, and Alzheimer's disease, all of which increased the risk for poor wound healing and skin breakdown. The care plan identified risks for skin breakdown and previous pressure ulcers, but did not address the need for the post-op shoe following the amputation. Observations documented the resident sitting in various locations without the protective shoe on the surgical foot, and staff interviews confirmed that the care plan had not been updated to reflect the post-surgical needs. Family members also reported that during their visits, the resident's right foot was not protected as instructed by the post-op orders. Staff interviews further highlighted the lack of communication and documentation regarding the post-op shoe. Nursing staff and nursing assistants were unsure about the presence of an order for the shoe, its purpose, or the correct application. The facility's policy required care plans to be updated with changes in the resident's condition, but this was not done after the resident's surgery. As a result, the resident's surgical site was not consistently protected as prescribed, and staff actions did not align with the physician's post-operative instructions.