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Based on interview and record review, the facility failed to effectively implement a process improvement based upon a patient grievance.

The facility failed to document the plan for staple removal for 2 of 3 current sampled patients (Patients #2 & # 6) with surgical staples.

Findings include:

TX00207860

Record review on 1/22/2015 of intake TX00207860 revealed complainant expressed concerns about the post-operative care of Patient #7. Specific concern was expressed as follows: " ...Patient #7's surgery was 7/10/2014 ...his surgical tape and staples stayed in after the 7 days plus 13 till we saw the doctor who then asked why the surgical tape and staples were still in when he wrote the order to remove after 7 days ..."

Interview on 1/23/15 at 8:50 am with facility Quality Director #50 stated "We were aware of concerns and have implemented a new process to improve communication. "

Review of facility letter to complainant, dated August 4, 2014, read: "We understand your concern to be the following: ...Staples being left in too long; while our usual process is to have the ortho surgeon remove these, especially when a follow up appointment is identified, we do take some ownership in the communication between such and have no identified a process to ensure the facility is aware of the ortho's preference ...".

Interview on 1/23/15 at 8:55 am with facility Quality Director #50 reported that during the Weekly Team Conference, patient issues were discussed such as removal of indwelling catheters, peripherally inserted central catheters (PICC) lines, etc. Surgical site staples were added to the list of concerns addressed. Facility Quality Director #50 said Nursing was to document the presence of staples on the "Nursing Weekly Summary" sheet. In this way, the plan for staple removal could be addressed. Facility Quality Director said that this new process was implemented early August 2014.

Record review on 1/23/15 at 3:30 pm of three (3) current patients with surgical staples revealed 2 of 3 patients (Patients #2 and #6) failed to contain documentation on the "Nursing Weekly Summary" sheet of surgical staples and orthopedic preference for removal. Quality Director #50 acknowledged the process needed further improvement.

Based on interview and record review the facility failed to ensure that a Registered Nurse (RN) supervised the care for 1 of 11 sampled patients (Patient #7).

Nursing failed to obtain a physician's order for post-operative staple removal per professional nursing standards and facility policy.

Findings include:

TX00207860

Record review on 1/22/2015 of intake TX00207860 revealed complainant expressed concerns about the post-operative care of Patient #7. Specific concern was expressed as follows: " ...Patient #7's surgery was 7/10/2014 ...his surgical tape and staples stayed in after the 7 days plus 13 till we saw the doctor who then asked why the surgical tape and staples were still in when he wrote the order to remove after 7 days ..." Complainant documented the staples were removed by the surgeon on 07/30/14, 20 days after the surgery.

Record review of Patient #7's clinical record revealed he was 58 years old and was admitted to the facility on 07-15-14 for rehabilitation following a fall resulting in a left femur fracture. Patient #7 underwent an open reduction internal fixation of the fracture.

Review of physician orders for Patient #7 failed to reveal a physician order for staple removal.

During a tour on 1/23/15 of the unit to which Patient #7 had been admitted, several nurses were interviewed regarding the process for surgical staple removal. The nurses were asked if a newly admitted post-operative patient had surgical staples, how would they know when to remove them?

Interview on 1/23/15 at 9:45 am with facility Licensed Vocational Nurse (LVN) #53 stated "she would get a doctor's order. "

Interview on 1/23/15 at 9:55 am with facility Registered Nurse (RN) #54 stated "usually staples stay in for 2 weeks, if still in, I would call the doctor for orders."

Interview on 1/23/15 at 10:00 am with facility RN #55 stated "staples usually stay in from 7 to 10 days, when near 10 days, I would call a physician for orders."

Interview on 1/23/15 at 1:45 pm with Nurse Manager #62 stated "The nurses would find out when staples were inserted. They are usually in for 7 to 10 days. At this point, the nurses would call for a physician's order for removal."

Review of facility policy titled: "Clinical Policy, Procedure and Guideline Resource Availability", dated 2/2014, read: " ...3. Unless otherwise defined ... clinical staff follows Lippincott Nursing Skills and Procedures for nursing procedures."

Review of facility reference " Lippincott Manual of Nursing Practice, " 9th Edition, read: " ..."If your facility allows you to remove skin staples and clips, verify the practitioner's order to confirm the exact timing and details for this procedure."