Failure to Follow Physician Orders for Staple Removal and TLSO Brace Use
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and hospital after-visit instructions for two residents. One resident was admitted with osteomyelitis of the ankle and foot, a left below-knee amputation, and protein calorie malnutrition, and had severe cognitive impairment. The hospital After Visit Summary specified that staples from the left below-knee amputation stump were to be removed in four weeks at a scheduled vascular surgery follow-up appointment. The day after admission, a physiatry PA entered an order for staple removal per protocol. The wound care LPN and the PA observed that the staples were overgrown with skin and, uncertain how long the staples had been in place and without recalling a review of the AVS recommendations, proceeded to remove the staples at the facility, causing some bleeding. This removal occurred 17 days before the AVS-documented timeframe for staple removal and before the vascular surgeon could see the resident and review the chart. The second resident was admitted with an unspecified fracture of the T9–T10 vertebra and muscle disorders, had severely impaired cognition, and required staff assistance with bed mobility and transfers. Physician orders directed that a TLSO back brace be worn whenever the resident was out of bed and that the brace be applied before the resident was weight bearing. On multiple observations over several days, the resident was seen sitting up in a wheelchair or stationary chair, including in the dining room, without the back brace applied, while the brace was observed on the dresser in the room. A family member stated the resident was supposed to have the brace on whenever out of bed and did not know why it was not applied. The care plan and progress notes contained no documentation of refusals to wear the brace, although an LPN reported the resident tended to remove the brace and acknowledged it should be documented if the resident removed or refused it. A facility policy stated it is the responsibility of the licensed nurse to follow physician orders.
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