Failure to Obtain and Implement Orders for Scalp Laceration and Staple Care
Penalty
Summary
Surveyors identified that the facility failed to consistently assess and monitor a scalp laceration for one resident. Observation showed the resident had an intact laceration on the right side of the scalp with one staple protruding, and the resident could not recall when or why the staple was placed. Record review revealed the resident had an unwitnessed fall that resulted in a right scalp laceration and transfer to the ED, after which the resident returned to the facility. A subsequent physician/PA/NP note documented that the resident had a fall with head trauma and laceration, that a staple was intact, and that it should be removed as directed, with continued supportive care and monitoring of mentation. Further record review showed that none of the resident’s care plans contained interventions for cleansing, monitoring, or assessing the laceration, and there was no documented order specifying a date or plan for staple removal. The MAR and TAR for the relevant months contained no physician orders for laceration care or assessment, and physician orders over the same period did not include any orders for laceration care or staple removal. In interviews, the ADON acknowledged that a physician order should have been obtained and documented for care, monitoring, and timely removal of the staple, and the NHA stated that nursing staff were responsible for ensuring appropriate orders and follow-up care were obtained and implemented. The facility’s policy stated that skin staple, suture, and clip removal would be provided in accordance with professional standards of practice.
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