PureHealth Arlington: Immediate Jeopardy Drain Care - TX

The 83-year-old resident arrived at the facility on a Tuesday with a drain tube inserted in her abdomen following surgery for a perforated duodenal ulcer. None of the nursing staff obtained orders from her surgeon for monitoring or caring for the drain.

By Saturday, purulent discharge was oozing from the surgical site. The drain bag had stopped working and contained no drainage since her admission. When a certified nursing assistant noticed the leak during routine care, the resident was sent to the hospital emergency room.

Hospital records show cultures from the infected drain grew Klebsiella bacteria, a common healthcare-associated infection that spreads through contaminated environments. Surgeons had to replace the infected drain and reposition it when it migrated out of place. The resident required multiple intravenous antibiotics and was hospitalized for several days.

Federal inspectors found the facility failed to ensure nursing staff were competent to care for residents with drains and tubes. The violation received an "immediate jeopardy" designation, meaning residents faced serious injury or death.

RN A admitted the resident on the Tuesday evening shift. She told inspectors she assumed treatment orders were already in place because the woman was transferring from the hospital attached to the facility. "She stated that she did not ask about the drain during report," according to the inspection.

The nurse acknowledged her responsibility to notify the facility physician to obtain orders or call the hospital for clarification. "She stated that it was neglect that she did not obtain orders to care for Resident #1," inspectors wrote.

When asked about the risk of not having drain care orders, RN A told inspectors: "She stated the risk was infection for not knowing how to care for Resident #1's drain."

The resident's family member grew increasingly frustrated as the days passed. He mentioned the drain to the facility physician on Wednesday, noting it was not producing any drainage. The physician said he would contact the surgeon but only left a voicemail and never received a response.

"Family stated that the facility physician did not even look at the drain," according to inspection records. "He stated that he did not see any nurses observed drain site or check the drain while he was in the facility."

LVN C took over the resident's care on Wednesday when she was moved to a different hallway. The nurse knew the resident had no orders for drain care but only assessed the skin around the dressing. "She stated that she could have reached out to the physician for orders," she told inspectors. "She stated the risk to Resident #1 was neglect for not having orders to care for her drain."

The resident's clinical admission assessment made no mention of the drain. Her care plan failed to address the stomach tube. The facility's medication and treatment records showed no orders for wound care, dressing changes, or drain monitoring from admission through the day she was hospitalized.

Progress notes revealed telling gaps. On the day of admission, RN A documented an "incision at the RUQ with a draining tube, the dressing is clean dry and intact." But no progress notes mentioned the drain during skin checks, incontinence care, or bathing between admission and hospitalization.

The first progress note to mention anything about the drain came on Saturday at 6:31 PM - the day the resident was sent to the emergency room. "An assessment of the abdomen revealed abdominal pain," RN D wrote. "Primary care provider recommendation was to send Resident #1 to the emergency room."

Thirty minutes later, RN D documented the emergency: "Purulent discharge observed from surgical drain site. Drainage bag doesn't seem to be working, right, and no drainage has been noted since patient's admission into facility. Surgical site warm to touch."

The wound care nurse examined the site, took photographs, and changed the dressing. The facility physician ordered the resident sent to the emergency room immediately.

Hospital records detail the severity of the infection. The resident was evaluated by both a surgeon and an infectious diseases specialist, who diagnosed a post-operative intra-abdominal abscess related to the infected drain. The drain had to be flushed with saline every 12 hours, and doctors ordered a follow-up CT scan.

Multiple staff members acknowledged the failure during inspector interviews. The assistant director of nursing said orders "drive care" and not having them "placed Resident #1 at risk of not getting drain care and infection."

RN D, who worked the evening shift when the infection was discovered, was direct about the consequences: "She stated Resident #1 was neglected because no one got orders to care for her drain. She stated the risk for not providing care to the surgical site was infection."

The director of nursing admitted the facility "had dropped the ball on Resident #1's lack of care orders for her drain." She said an interdisciplinary team meeting was held to identify where they went wrong.

The facility physician told inspectors it was "common sense and a nurse best practice to clean the skin around the incision, to monitor output and to report change." He acknowledged there was "a risk for infection if not monitored."

CNA B, who first noticed the leaking drain, had been aware the resident came to the facility after a surgical procedure but was not allowed to access the drain or empty the drainage bag as a certified nursing assistant. "He stated that he notified family because family was in the room and that family was very involved with resident."

The administrator said the facility admits 60 to 80 residents each month and expected nursing staff to communicate effectively and obtain physician orders as needed. He stated the wound care nurse present during the resident's admission was later terminated "due to failure to report and other issues."

Following the incident, the facility conducted emergency training for all nursing staff on competent nursing care and infection control. The training covered ensuring treatment orders are in place for all drains, tubes, and catheters, recognizing signs of infection, and completing effective head-to-toe assessments within 48 hours of admission.

Staff who had not completed the training by the deadline were not permitted to work until they received instruction. The facility implemented monitoring procedures including cross-checking progress notes for drain orders and having the wound care nurse perform assessments on all new admissions within 48 hours.

The immediate jeopardy designation was removed after the facility implemented corrective measures, but inspectors noted the facility remained out of compliance while monitoring the effectiveness of their plan.

The resident's family member told inspectors he was frustrated that his relative was admitted without proper discharge paperwork and that staff failed to properly monitor her drain despite his repeated concerns. His loved one's preventable infection and hospitalization illustrated the human cost when basic nursing protocols are ignored.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Purehealth Transitional Care At Thr Arlington from 2024-07-03 including all violations, facility responses, and corrective action plans.

Additional Resources

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