The coding error at Lakeside Health and Wellness meant orders for staple removal never appeared on the Treatment Nurse's daily task list, according to the facility's Director of Nursing during a November 19 inspection.
The DON told inspectors that physician orders are reviewed during morning stand-up meetings. But the removal order for Resident #4 was "inaccurately coded in the EMR program," preventing it from being placed correctly on the Treatment Assignment Record that guides nursing tasks.
She acknowledged the failure could cause serious harm. "The staples not being removed could result in further injury if the staples become embedded in the skin or infection," the DON stated during her interview.
The Administrator echoed these concerns during a 5:29 p.m. interview the same day. All residents would be at risk if nursing staff continued to input orders incorrectly into the electronic medical records system, the Administrator said.
"Failure to follow physician's orders could result in residents not receiving the appropriate care as directed by the physician," the Administrator told inspectors.
The DON promised to conduct additional training to ensure floor nurses understand how to properly enter orders in the EMR system. But when inspectors requested the facility's Skin and Wound Management policy at 4:50 p.m., they never received it before the survey concluded.
The violation represents a breakdown in the facility's medication and treatment administration systems. Federal regulations require nursing homes to ensure that residents receive treatments and medications as prescribed by their physicians.
Computer coding errors that prevent medical orders from reaching nursing staff create systematic risks for patient care. When removal orders for surgical hardware like staples fail to appear on daily task lists, residents face prolonged exposure to foreign objects that should be temporary.
Surgical staples typically require removal within seven to fourteen days after placement, depending on the location and healing progress. Extended retention can lead to tissue overgrowth around the staples, making removal more difficult and painful. In severe cases, staples can become permanently embedded, requiring surgical intervention.
The incident highlights broader concerns about electronic medical record systems in nursing homes. While EMR technology can improve care coordination when functioning properly, coding errors can create dangerous gaps in treatment delivery.
The facility's morning stand-up meetings were designed as a safety net to review physician orders. But this system failed to catch the coding error that prevented Resident #4's staple removal from appearing on nursing assignments.
Training gaps among floor nurses contributed to the problem. The DON's promise of additional EMR training suggests staff lacked adequate knowledge of the computer system's order entry requirements.
The Administrator's acknowledgment that all residents faced similar risks indicates this was not an isolated incident. Systematic problems with order entry could affect multiple patients receiving various treatments and medications.
Inspectors found the violation during a complaint investigation, suggesting someone reported concerns about care quality at the facility. The specific nature of the complaint was not detailed in available records.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the Administrator's statement about facility-wide risks suggests the scope could be broader than initially assessed.
The facility's failure to provide requested policies to inspectors raises additional questions about administrative cooperation and documentation practices. The Skin and Wound Management policy would have shown whether proper procedures existed for tracking and completing treatment orders.
Resident #4's experience demonstrates how technical failures can translate into real patient harm. What should have been a routine post-surgical procedure became a potential source of infection and injury due to administrative breakdown.
The DON's recognition that embedded staples could require additional medical intervention underscores the seriousness of seemingly minor administrative errors in healthcare settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakeside Health and Wellness from 2025-11-19 including all violations, facility responses, and corrective action plans.