Failure to Implement Restorative Care Plan for C-Collar Use
Penalty
Summary
The facility failed to create and implement a Restorative Care Plan for a resident who had a physician's order to wear a C-collar at all times. Observations revealed that the resident was often found lying in bed without the C-collar, and there was no care plan in place for its use. The resident was observed at different times of the day, appearing tired and disoriented, but without visible signs of distress or discomfort. The resident's medical records indicated a diagnosis that required the use of a C-collar, with specific instructions to keep it in place at all times, except during care, and to inspect the skin for abnormalities every shift. However, interviews with staff revealed inconsistencies in following these orders. A Registered Nurse acknowledged the requirement for the C-collar to be worn constantly, while a Restorative Certified Nursing Assistant noted that the resident often did not like to wear it while sleeping or in the dining room. The C-collar was found to be in the laundry, wet, and not available for immediate use. The Director of Nursing confirmed that staff monitored the resident every two hours and mentioned the resident's participation in a prevention program. Despite this, there was no new order received for the removal of the C-collar after a CT scan was conducted. The facility's policy requires that physician orders be followed as prescribed, and any deviations must be documented in the resident's medical records, which was not done in this case.
Plan Of Correction
Identify patients that were at risk and what did: Patient #43. Care plans were updated accordingly, and different interventions were made. Regarding Resident #43, the brace was added to the care plan. All other residents with similar devices were also identified and care plans verified. How will you identify other patients that are at risk: Regarding Resident #43, the brace was added to the care plan. All other residents with similar devices were also identified and care plans. (Audit Tool) Measures put in Place: Upon admissions, residents are assessed for devices. Any devices such as braces or other devices are reviewed upon admission and reviewed in our morning meeting. During the morning meeting, the MDS Coordinator will update and validate the team when this is completed. Restorative Nursing will be maintaining a weekly checklist of all new devices and will be addressed on care plan. Also, training was completed for care plan team members regarding floor mats, C-Collars, devices, and following physician orders, and nursing to communicate anytime a resident refuses treatment such as the C-Collar. This will be reported and presented to the QAPI committee to ensure compliance. How will you monitor: The Director of Nursing, MDS Coordinators, Restorative Nurse, and/or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur monthly for 3 months, then quarterly and/or if any variances are reported ongoing.