Incomplete Clinical Record for Surgical Drain Removal
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident who returned from surgery with a surgical drain in place. Upon review, it was found that there was a physician's order for daily dressing changes and for the drain output to be recorded every 12 hours, with instructions for the drain to remain in place until the resident's follow-up clinic visit in approximately one week. However, documentation showed that the drain was removed at the facility just one day after the resident's return, following a phone call to the surgical center nurse, but without any written or verbal order from the medical provider or surgical team authorizing the removal. The clinical record lacked evidence of such an order, and this was confirmed during interviews with the charge nurses and the Director of Nursing.