Failure to Transcribe and Initiate Post-Hospitalization Orders for Hematoma Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards following a hospitalization for a fall resulting in a head abrasion and hematoma. Upon the resident's return from the emergency department, the facility did not review or transcribe the hospital's discharge instructions and physician orders into the electronic medical record (EMR). As a result, prescribed treatments for the abrasion and hematoma, including wound care, application of ice and heat, elevation of the affected area, and monitoring for complications, were not initiated or documented by nursing staff. The resident, who was over 65 years old and had multiple comorbidities including stage four kidney disease, diabetes, atrial fibrillation, and dementia, was non-ambulatory and required significant assistance with mobility. The resident was also prescribed anticoagulant therapy, increasing the risk of complications from hematomas. After a fall from a wheelchair, the resident was evaluated at the hospital, where imaging ruled out internal bleeding, and specific aftercare instructions were provided for both the abrasion and hematoma. Record review revealed that the medication reconciliation form was left blank and unsigned, and there was no documentation in the resident's comprehensive care plan regarding the required treatments or monitoring for the abrasion and hematoma. Interviews with the Director of Nursing confirmed that the discharge instructions were not reviewed or entered into the EMR, and that nursing staff were unaware of the specific care needs. Consequently, the resident did not receive the prescribed post-hospitalization care for the injuries sustained.