Failure to Assess, Monitor, and Report Surgical Site Infection
Penalty
Summary
The facility failed to ensure that a resident received necessary medical attention and comprehensive assessment following a change in her left hip surgical incision. After undergoing surgery for a left subtrochanteric femur fracture, the resident's incision was initially documented as healing well, with no drainage or pain. However, after staple removal, there were periods where no documentation was made regarding the incision, and when changes such as redness, purulent drainage, and tenderness were observed, these were not promptly reported to the provider. Nursing staff did not consistently assess, monitor, or document the condition of the surgical site, despite orders for daily dressing changes and assessments. When signs of infection, including purulent drainage, erythema, and pain, were noted, there was a lack of timely communication with the provider. Nursing assistants reported changes to the nursing staff, but these concerns were not documented or escalated as required. The provider was not notified immediately when infection indicators appeared, and documentation of assessments and interventions was inconsistent. Interviews with staff confirmed that the expected protocol was not followed, and that the provider should have been contacted as soon as infection was suspected. As a result of these failures, the resident developed a post-surgical abscess and sepsis, requiring hospitalization, surgery, and the insertion of a PICC line for IV antibiotics. The hospital records indicated that the infection had progressed significantly by the time of transfer, and staff interviews acknowledged that earlier recognition and intervention could have prevented the escalation. Facility policies required daily assessment and documentation of wounds, as well as prompt provider notification for signs of infection, but these were not adhered to in this case.