Failure to Provide Post-Vascular Procedure Care and Follow-Up
Penalty
Summary
The facility failed to provide adequate and necessary comprehensive, resident-centered care to a resident following a vascular procedure for arterial stenosis. After undergoing an angiogram and stent placement, the resident was discharged with physician orders to receive Plavix 75 mg daily and Aspirin 81 mg daily to maintain stent patency and prevent complications. However, the medical record revealed that the resident had not received Aspirin since the previous year, and Plavix was never administered after being ordered. There was also no care plan addressing the resident's post-procedure care, follow-up appointments, or transportation needs. The resident, who had multiple comorbidities including diabetes, peripheral vascular disease, dementia, and chronic kidney disease, required assistance with activities of daily living and had a history of arterial/ischemic ulcers. Despite the physician's orders and the resident's high risk for complications, the facility failed to arrange transportation for follow-up appointments with the vascular surgeon. The lack of a contract with a non-emergent ambulance service resulted in multiple missed appointments, and the facility did not reschedule or ensure the resident was evaluated by the vascular surgeon after the procedure. As a result of these failures, the resident's arterial wounds deteriorated, leading to the development of osteomyelitis in the left foot. The wounds showed signs of infection, including purulent drainage, necrotic tissue, and exposed bone. The resident ultimately required emergent transport to the hospital, where intravenous antibiotics were initiated for the treatment of osteomyelitis. Interviews with facility staff confirmed the missed medication administration and transportation issues, as well as a lack of awareness regarding the resident's missed follow-up care.