The December 30 federal inspection at Dexter Health Care found that staff violated medical record requirements when they pulled the drain from Resident #1 on December 24, contradicting explicit instructions from the surgical center.
The resident had undergone an amputation and returned to the facility on December 23 with a surgical drain that was supposed to remain in place for approximately one week until a follow-up clinic appointment. Medical orders dated December 23 specifically instructed nursing staff to change the surgical wound dressing daily and record drain output every 12 hours, with the drain staying in place until the first follow-up visit.
Instead, nursing documentation shows the drain was removed on December 24.
According to the inspection report, the nurse documented that she "found the drain almost out" and called the surgical center. She wrote that a nurse at the surgical center told her "to go and pull the drain." However, inspectors found no evidence in the clinical record of any written or verbal order from the medical provider or surgical team authorizing removal of the drain.
The Treatment Administration Record for December and nursing notes for the resident confirmed the drain was removed at the facility on December 24, just one day after the resident's return from surgery.
During the inspection, the Director of Nursing confirmed to surveyors that the resident's clinical record contained no written or verbal order to remove the surgical drain.
The violation represents a breakdown in basic medical record keeping requirements. Federal regulations require nursing homes to maintain complete and accurate medical records that follow accepted professional standards, particularly for residents with surgical wounds requiring specific post-operative care.
Surgical drains are typically placed during operations to prevent fluid buildup that could lead to infection or other complications. The timing of drain removal is a medical decision that requires physician oversight, as premature removal can result in fluid accumulation, delayed healing, or other post-surgical complications.
The inspection classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The facility must develop a plan of correction to address the medical record deficiencies identified during the complaint investigation.
The case highlights ongoing challenges nursing homes face in maintaining proper documentation and following medical orders, particularly for residents requiring complex post-surgical care. When staff deviate from established medical protocols without proper authorization, it creates gaps in the medical record that can compromise patient safety and continuity of care.
Federal inspectors noted that any deficiency related to medical record accuracy and completeness requires immediate attention, as incomplete records can lead to medication errors, missed treatments, or inappropriate care decisions by other medical professionals.
The resident's surgical wound required daily dressing changes by the facility's care team, with drain output monitored every 12 hours as part of the post-operative care plan. The unauthorized drain removal disrupted this carefully structured recovery protocol designed by the surgical team.
Dexter Health Care must now demonstrate how it will ensure nursing staff follow written medical orders precisely and obtain proper authorization before deviating from established treatment protocols. The facility must also show how it will maintain complete and accurate documentation of all medical decisions affecting resident care.
The inspection findings will be publicly disclosed, and the facility's plan of correction must be approved before it can continue participating in Medicare and Medicaid programs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dexter Health Care from 2025-12-30 including all violations, facility responses, and corrective action plans.