Failure to Follow Physician Orders for Staple Removal
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with physician orders and professional standards of practice. Specifically, a male resident with multiple diagnoses, including congestive heart failure, hypertension, diabetes type II, chronic kidney disease stage 3, and peripheral vascular disease, returned from the emergency room with two staples in the back of his head following a fall. Physician orders directed that the staples be removed five days after insertion. However, the order to remove the staples was not properly entered into the electronic medical record (EMR) system, resulting in the treatment not being scheduled or completed as ordered. Observations and interviews revealed that the treatment nurse was monitoring the staples but was unaware of the removal order due to the order not appearing on the Treatment Administration Record (TAR). The MDS nurse was aware of the presence of staples and the scheduled removal but did not know if the removal had occurred. The DON confirmed that the order was inaccurately coded in the EMR, preventing the treatment nurse from being prompted to remove the staples. The resident was observed with staples still in place beyond the ordered removal date, and the issue was only identified during the survey process.