F0684

G

Failure to Coordinate Post‑Op Follow‑Up, Therapy, and ADL Care for Post‑Surgical Resident

Richton Park, Illinois Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered post‑operative follow‑up care, therapy, and ADL assistance to a cognitively intact male resident admitted after bilateral hip ORIF. The resident had a clearly documented post‑op follow‑up appointment with orthopedics, including date, time, location, and contact information, listed both in the physician order summary and prominently on the first page of the hospital discharge summary. The admitting nurse was expected to communicate this to the scheduler per facility procedure, but the appointment on 2/3 was not scheduled, and the DON later attributed this to miscommunication. A subsequent appointment arranged by the facility was not completed because the ambulance arrived without a stretcher, and another rescheduled appointment was missed when the ambulance did not show up. These missed appointments were not documented in the medical record, and the physician was not notified.

The facility also failed to ensure the resident received therapy as ordered. Physician orders dated 1/27 and 1/29 included PT evaluation and treatment three times weekly for four weeks, and PT/OT/ST evaluation and treatment for 30 days. The Therapy Director reported that therapy saw the resident for two weeks and then stopped due to a non‑weight‑bearing order from orthopedics, and that they were waiting for an updated weight‑bearing order from the follow‑up appointment that never occurred. As of mid‑February, the resident was still not in therapy, despite orders indicating that post‑operative therapy should begin upon admission. There was no indication in the record that alternative therapy interventions, such as upper body training, were consistently provided within the constraints of the non‑weight‑bearing status.

The facility further failed to provide necessary ADL care and monitoring of the surgical site. The MDS documented that the resident was cognitively intact but required substantial/maximal assistance for most ADLs and was dependent for toileting and transfers, with a care plan reflecting these needs. The resident reported not receiving showers or bed baths, having to attempt transfers independently because call lights were not answered, and having episodes of incontinence where he remained in urine and feces for hours without assistance. Surveyors observed a full urinal on the bedside table with food and personal items, and later an almost full urinal on the bed rail, which staff acknowledged should have been emptied. Nursing staff did not document required shift assessments of the surgical site, and the DON was unsure when staples should be removed. On observation, the right hip surgical site was swollen and painful, and a venous doppler later showed findings likely due to DVT. The resident stated he felt hopeless and believed no one cared about his pain or healing process.