Failure to Follow Physician Orders and Provide Proper Post-Surgical Wound Care
Penalty
Summary
The facility failed to provide care and treatment in accordance with physician orders and accepted standards of practice for a resident who underwent a left breast lumpectomy. The resident was not maintained on NPO (nothing by mouth) status after midnight prior to surgery, despite a clear physician order, and was given a bowl of cereal for breakfast on the morning of the scheduled procedure. This resulted in a delay of the surgery, as documented in the surgeon's assessment and plan. The facility's own policies require strict adherence to physician orders, including those related to pre-operative care. Following the resident's return from surgery, the facility did not obtain or follow physician orders for wound care to the surgical site. There was no documentation of wound care orders or treatments for the surgical incision for an extended period, and wound care, including the application of steri-strips and dressings, was performed without a physician order. The resident reported that a dressing was left unchanged for three weeks, and when it was finally removed, there was thick yellow drainage present. The facility's policies state that wound treatments must be provided according to physician orders and that, in the absence of such orders, the physician should be notified to obtain them. Additionally, the facility failed to perform and document accurate weekly head-to-toe skin assessments, as required by the resident's care plan and facility policy. Multiple weekly skin assessments did not include any mention of the left breast surgical wound, despite its presence and subsequent complications, including dehiscence and infection. Interviews with staff and administration confirmed that there was an expectation for thorough assessment and documentation of all open areas, including surgical incisions, and that these expectations were not met in this case.