Failure to Promptly Notify Provider of Post-Surgical Infection
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify a physician of a significant change in a resident's condition following hip surgery. The resident, who had a history of a left subtrochanteric femur fracture treated with open reduction and internal fixation, developed signs of infection at the surgical site, including purulent drainage, erythema, swelling, and pain. Documentation shows that from 8/27 through 8/31, there was no recorded assessment of the surgical incision, despite daily dressing changes being required. On 9/1, the resident exhibited clear signs of infection, such as purulent drainage and tenderness, but there was no evidence that a provider was notified at that time, nor was this action documented. Nursing staff and nursing assistants observed and reported changes in the resident's incision, including increased redness, drainage, and pain, to the nurse on multiple occasions. However, these observations were not consistently documented, and the provider was not contacted promptly. Interviews with staff confirmed that the expected protocol was to notify a provider immediately when signs of infection were present, such as purulent drainage, redness, and pain. The provider was not contacted until several days after the initial signs of infection appeared, and only after the resident's condition had further declined, resulting in the need for hospital transfer. The resident was ultimately hospitalized with a diagnosis of sepsis due to a post-surgical abscess, requiring intravenous antibiotics and surgical intervention. Facility policy required daily assessment and documentation of wounds, as well as immediate provider notification upon identification of infection signs. The failure to assess and document the surgical site daily, combined with the delay in notifying the provider of significant changes, directly contributed to the deficiency identified in the report.