Failure to Provide Post-Surgical Care Planning and Monitoring
Penalty
Summary
The facility failed to establish and implement appropriate care plans, assessments, and monitoring for residents following orthopedic surgeries, specifically after total knee replacement and hip fracture procedures. For three residents reviewed, there was a lack of individualized care planning and failure to document or provide necessary interventions related to post-surgical care, including the use and monitoring of compression stockings (ted hose) and assessment for edema. Orders for post-surgical care, such as dressing changes, compression stocking use, and monitoring for edema, were not incorporated into the residents' care plans, and staff did not consistently follow or clarify these orders. One resident, who had a recent total knee replacement and a history of atrial fibrillation and peripheral vascular disease, experienced increased pain in the right foot that went unassessed for six days. Staff did not remove the compression stocking to visualize the skin or assess the source of pain, despite the resident's complaints and the presence of risk factors for blood clots. There was no documentation of staff attempts to assess the area, no notification to the provider regarding the resident's pain or refusal (if any) to allow assessment, and no updates to the care plan to reflect the resident's post-surgical needs. When the compression stocking was finally removed, significant discoloration and tissue damage were discovered, leading to hospital transfer and surgical intervention for a blood clot. Interviews with staff revealed confusion and lack of clarity regarding responsibility for care plan updates, assessment protocols, and communication with providers. Staff reported not removing compression stockings for skin checks, not documenting refusals, and not notifying providers of changes in condition or unclear orders. The care plans for other residents with similar post-surgical needs also lacked necessary interventions and monitoring instructions, further demonstrating a systemic failure to provide care according to physician orders and resident needs.