F0658

D

Failure to Maintain and Monitor Post‑Operative Surgical Dressing per Physician Orders

Modesto, California Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure nursing services met professional standards of practice for a post‑operative resident whose surgical dressing was ordered to be kept clean and dry, with instructions to notify the physician if there was a problem with the bandage. The resident, cognitively intact per a BIMS score of 15/15, had undergone right foot surgery involving arthrodesis of the 2nd, 3rd, and 4th toes and had comorbidities including type 2 diabetes mellitus, orthopedic aftercare needs, and osteoarthritis. The physician’s post‑operative order directed that the sterile surgical bandages be kept clean and dry, that no bandage change was needed, and that the office be notified if there was a problem with the bandage. There was no order in the record to monitor the dressing for cleanliness or dryness, and the DON later stated there was no policy and procedure available for following physician orders or professional standards of practice.

The resident reported that approximately a week and a half after surgery, a CNA prepared him for a shower by placing a clear plastic trash bag over his right foot and securing it with tape to keep the dressing dry. During the shower, the tape slid down his leg, allowing water to enter the bag. After the shower, when the resident removed his foot from the bag, he observed about three inches of water in the bottom of the bag and noted that his dressing was wet. The resident stated he notified the nurses that his dressing was wet, but the nurses did not change or reinforce the dressing, and he kept the wet dressing in place for four to five days until his post‑operative visit with the podiatrist. CNA 1 confirmed that the process used to keep a dressing dry during showers was to place a plastic trash bag around the foot and secure it with tape.

At the podiatry follow‑up visit, the podiatrist documented that the resident reported he had wet his dressings in the shower the prior Wednesday and did not think they needed to be changed or that it was a serious matter. The podiatrist’s exam noted that the dressings were soiled and malodorous, with some dehiscence proximally to the 2nd toe incision, erythema and increased warmth to the dorsal midfoot, and skin maceration. The podiatrist assessed cellulitis and prescribed oral antibiotics, which were later approved by the attending physician and started at the facility. The treatment nurse and DON both stated that, based on the order to keep the dressing clean and dry, nursing staff should have contacted the physician if the dressing became wet, and the DON acknowledged there were no nurses’ notes indicating whether the bandage became wet during showers and no care plan addressing the cellulitis or antibiotic use. The facility’s LVN and DON job descriptions required adherence to professional standards of nursing practice and physician orders, and the wound care policy referenced reporting information in accordance with facility policy and professional standards of practice, but these standards were not followed when the resident’s wet, soiled surgical dressing was not addressed or reported as ordered.

A subsequent office visit note from the podiatrist documented that the resident reported the forefoot dressing had come off and the foot was soaked in water for an unknown period, with persistent swelling and burning between the lesser toes, and that he was taking the prescribed antibiotic. The DON stated she did not have documentation that the dressing became wet in the facility shower and that the resident sometimes refused to allow staff to check his dressing, but also stated that the expectation was for staff to keep extremity dressings dry during showers using plastic wrap secured with tape and to call the physician if the dressing became wet. The professional reference reviewed by surveyors indicated that nurses cannot arbitrarily decide which physician orders to follow and that failing to carry out orders can be grounds for discipline and may be deemed neglect, underscoring that the failure to keep the surgical dressing dry and to notify the physician when it became wet did not meet professional standards of practice.