CALVERT CITY, KY - Federal inspectors issued immediate jeopardy violations against Oakview Nursing & Rehabilitation Center after staff failed to follow physician-ordered wound care for a post-surgical resident, resulting in cellulitis, sepsis, and emergency hospitalization.
The June 13, 2024 inspection revealed that a 66-year-old resident with ankle fractures received inadequate post-operative care that led to a serious infection requiring intravenous antibiotics and extended hospitalization.
Post-Surgical Care Breakdown
The resident, identified as R66 in inspection documents, was admitted to Oakview on April 22, 2024, following multiple ankle fractures from a fall. After undergoing open reduction internal fixation surgery on April 26, 2024, she returned to the facility the same day requiring specialized wound monitoring and care.
On May 3, 2024, the resident's podiatric surgeon provided specific orders for daily wound care, including cleaning surgical incisions with saline solution, applying Medi-Honey to wounds, and changing dressings daily. The family delivered these orders directly to facility staff.
However, inspection records show the facility failed to implement these critical post-operative care instructions. The surgeon's orders were not entered into the resident's medical record until May 16, 2024 - nearly two weeks later and after the resident had already been discharged to the hospital.
Family Raises Concerns
Family members reported that despite bringing written orders to the facility, wound care was not performed as prescribed. During interviews with federal inspectors, family members stated that dressings were not changed for seven to eight days following the surgeon's visit.
On May 14, 2024, when family members visited, they observed concerning signs: the dressing was saturated with drainage, had a foul odor, showed yellow-green discharge, and the ankle appeared red and swollen. When they asked Licensed Practical Nurse #8 to examine the wound, the nurse reportedly told them "the incision was not infected or swollen and if it were infected, the drainage would have been bright green in color."
Concerned by what they observed, family members photographed the wound and sent images to the podiatric surgeon, who immediately requested to see the resident in his office.
Medical Emergency Develops
When examined on May 15, 2024, the podiatric surgeon found clear evidence of infection and immediately sent the resident to the emergency room. Hospital records documented diffuse redness, swelling of the left ankle, and purulent, foul-smelling drainage from the surgical wounds.
Emergency room physicians determined the resident met sepsis criteria and initiated a comprehensive workup. Blood cultures confirmed the presence of Staphylococcus hominis and Staphylococcus epidermidis bacteria. The resident required immediate treatment with intravenous antibiotics including Vancomycin and Cefepime.
An infectious disease specialist later changed the antibiotic regimen to Clindamycin 600 mg every eight hours for fourteen days based on the specific bacterial cultures identified.
Critical Care Plan Failures
Federal inspectors found that Oakview failed to develop a comprehensive care plan for the resident's surgical wound care until May 7, 2024 - eleven days after her return from surgery. This delay violated standard nursing home protocols requiring care plans within 48 hours of significant medical changes.
The Assistant Director of Nursing, who also served as the facility's wound care nurse despite lacking certification in wound management, acknowledged that a care plan should have been implemented when the resident returned from surgery to ensure proper monitoring of surgical incisions.
Staff Communication Breakdown
Multiple nursing staff interviewed by inspectors revealed concerning gaps in communication and care coordination. Licensed Practical Nurse #8 stated she had not assessed the resident's wound until May 14, 2024, when the family specifically asked her to do so.
Several nurses reported being told during shift changes that the wounds were "not to be touched," creating confusion about appropriate care protocols. This miscommunication contributed to the lack of proper wound assessment and treatment.
Licensed Practical Nurse #3, who worked night shifts, admitted to documenting wound care that was never actually performed, stating "she was apparently completing the daily skilled charting note incorrectly" and that "the facility dropped the ball on R66."
Standard Post-Surgical Protocols
Post-operative wound care in nursing facilities requires systematic monitoring to prevent complications. Daily assessment should include checking for signs of infection such as increased redness, swelling, warmth, drainage changes, and odor. Any concerning changes require immediate physician notification.
Proper wound care protocols involve maintaining sterile technique during dressing changes, following specific cleaning instructions, applying prescribed topical treatments, and documenting all observations. When physician orders are received, they must be entered into the medical record immediately and implemented without delay.
The failure to follow these basic protocols can result in serious complications including cellulitis, abscess formation, and systemic infection leading to sepsis - a potentially life-threatening condition requiring emergency intervention.
Administrative Acknowledgment
During inspector interviews, facility leadership acknowledged multiple system failures. The Director of Nursing admitted the facility should have called the physician's office and obtained orders and implemented a care plan within forty-eight hours after the resident returned from surgery.
The Medical Director emphasized that orders are there for a purpose and should be followed, noting that any deviation from physician instructions should prompt immediate clarification calls.
The facility's Administrator stated he expected all residents to have necessary orders in place and comprehensive care plans to ensure appropriate care delivery.
Immediate Jeopardy Resolution
Federal inspectors notified Oakview of the immediate jeopardy violation on June 6, 2024. The facility submitted an acceptable removal plan on June 8, 2024, and inspectors validated that immediate safety threats had been addressed by that date.
The immediate jeopardy designation indicates that the facility's failures created a serious risk of injury, harm, impairment, or death to residents. This represents one of the most serious violation categories under federal nursing home regulations.
This case demonstrates how seemingly routine post-operative care requires vigilant attention to detail and proper care coordination. When multiple system failures occur simultaneously - missing physician orders, absent care plans, inadequate staff training, and poor communication - residents face serious health risks that can rapidly escalate to life-threatening conditions.
The incident resulted in extended hospitalization, additional medical treatment, and significant distress for both the resident and family members who entrusted the facility with post-surgical recovery care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oakview Nursing & Rehabilitation Center from 2024-06-13 including all violations, facility responses, and corrective action plans.
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