F0684

D

Failure to Implement Post‑Surgical Wound Care and Anticoagulant Therapy

Massillon, Ohio Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain and implement physician orders for post‑surgical wound care and monitoring, and to provide ordered anticoagulant therapy for post‑operative residents. One resident admitted after a right hip fracture repair had no physician orders for a surgical wound dressing or monitoring on admission or for the first several days of the stay. Physician orders for a dry dressing change to the right hip were not entered until four days after admission, and the treatment was not first implemented until the following day. The resident reported that the surgical wound was seeping, that when the facility removed the bandage it was not replaced for two days, and that after a shower when the dressing came off it was not reapplied; the resident also stated that the doctor and nurses did not look at the wound. A facility RN and a regional RN both confirmed there were no surgical wound orders until four days after admission and that the admitting nurse should have clarified with the physician and obtained post‑surgical hip fracture orders, at least to monitor the site.

A second resident admitted with a displaced intertrochanteric fracture of the right femur likewise had no physician orders for surgical wound dressing changes or for monitoring the surgical site on admission. Review of the MARs and TARs for this resident showed no orders for surgical wound dressings or wound site monitoring throughout the month. Both an RN and the regional RN confirmed there were no surgical wound orders and that the admitting nurse should have clarified with the physician and obtained post‑surgical hip fracture orders to monitor the site. A third resident admitted with a recent pacemaker placement had no admission orders for care of the pacemaker surgical site. Physician orders for surgical wound care for this resident were not entered until the day after admission, and only after surveyor intervention. The regional RN and another RN confirmed there were no surgical wound care orders until that time and that the admitting nurse should have clarified with the physician and obtained post‑surgical wound orders to at least monitor the site.

The deficiency also includes failure to ensure post‑operative anticoagulant therapy to prevent blood clots was in place and provided as ordered for two residents admitted after hip surgery. One resident’s hospital records showed an order for Enoxaparin 40 mg SQ every 24 hours and a postoperative plan specifying six weeks of chemical DVT prophylaxis with Lovenox after hip surgery. On admission to the facility, there were no physician orders for any anticoagulant, and the medical record contained no evidence of preventive measures being taken to prevent blood clots post‑surgery. The resident stated that blood thinners were never given from the first day of admission. The regional RN and another RN confirmed there were no anticoagulant orders, that the hospital should have been called by the admitting nurse for clarification, and that after post‑operative hip surgery an anticoagulant is prescribed unless contraindicated.

Another resident admitted with a right hip fracture and right foot fracture had hospital documentation indicating VTE prophylaxis with an anticoagulant after hip surgery was appropriate and critical for up to 35 days post‑surgery, and hospital referral records showed an order for Enoxaparin 40 mg SQ every 24 hours. Review of the facility physician orders revealed no anticoagulant medications for this resident, and the medical record contained no evidence of preventive measures to prevent blood clots post‑surgery. The regional RN confirmed there were no anticoagulant orders and that the hospital should have been called by the admitting nurse for clarification, and another RN confirmed the resident should have been on Lovenox at the facility and that the admitting nurse should have contacted the hospital regarding clarification of the anticoagulant. These failures occurred despite facility policies on wound care, anticoagulation, and medication administration that required verification of physician orders, identification of anticoagulated individuals including those with recent joint replacement surgery, and safe, timely administration of medications as prescribed.