Failure to Assess and Monitor Post-Surgical Resident Resulting in Neglect and Pressure Injuries
Penalty
Summary
The facility failed to provide necessary assessments and monitoring for a resident following a total right knee arthroplasty. Despite the resident having diagnoses that increased their risk for complications, such as atrial fibrillation and peripheral vascular disease, there were no physician orders for licensed staff to assess the resident’s right leg, including skin checks, pulse, movement, or sensation after surgery. The care plan was not updated to reflect the resident’s post-surgical needs, and there was no documentation of interventions or monitoring for the right leg. For eleven days after surgery, licensed nurses did not assess the resident’s right foot, and there was no evidence that the compression stocking was removed for proper skin assessment. Documentation in the medical record was lacking regarding any refusals by the resident to allow removal of the compression stocking, and late entries were made only after the resident was hospitalized. Staff interviews revealed that refusals were not communicated to the physician, and staff did not seek clarification on unclear physician orders regarding the use of compression stockings. Multiple staff members confirmed that they did not attempt to remove the compression stocking or notify the provider about the situation, and assumptions were made that other staff or shifts were handling the issue. The resident and their power of attorney both stated that staff never attempted to remove the compression stocking or assess the right foot, despite the resident experiencing significant pain and requesting attention to the area. As a result of these failures, the resident developed a blood clot that restricted blood flow to the right foot, required surgical intervention, and developed several pressure injuries. The lack of assessment, monitoring, care planning, and communication with the provider led to unmet care needs and avoidable skin issues. The facility’s own investigation confirmed the absence of timely notification, documentation, and care planning, which resulted in significant harm to the resident.