Lack of Comprehensive Care Plan for Resident with Cervical Collar
Penalty
Summary
The facility failed to ensure the development of a comprehensive person-centered care plan for a resident with limited range of motion, specifically regarding the use of a cervical collar. The resident, who was admitted with multiple diagnoses including fractures, was noted to have severely impaired cognition and required maximum assistance for activities of daily living. Despite the presence of a physician's order to monitor the skin and maintain the cervical collar, there was no evidence of a care plan addressing the fractures, positioning, cervical collar use, or skin integrity monitoring. Observations during the survey period confirmed that the resident consistently wore a cervical collar while in a wheelchair and in bed. However, the Registered Nurse Unit Manager acknowledged the absence of a care plan with specific goals and interventions for the cervical collar. Although an assessment documented the fractures, no new goals or interventions were added following the resident's most recent admission. This oversight was identified during the recertification survey, highlighting a deficiency in the facility's compliance with its policy on comprehensive care planning.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 F656 ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. What corrective actions will be accomplished for the resident found to have been affected by the deficient practice: - Nurse manager #10 was educated on identification of residents who have splints, braces, casts, immobilizers or cervical collars. Including care plan initiation, appropriate measurable goals and interventions to ensure residents identified have limited range of motion or potential for in place. - The resident #37 care plan was developed to specifically state limited range of motion due to cervical collar for c2 fracture on 2/24/25. How the facility will prevent occurrence from happening to other residents having the potential to be affected by same deficient practice: - All Residents have the potential to be affected by this practice. Any resident with splint, brace, cast, immobilizer or cervical collar, medical records were audited to ensure limited range of motion or potential for was care planed with appropriate goals and interventions. No occurrences found. This audit was completed by the DON/ADON on 2/25/25. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The policy titled, “Comprehensive care” was reviewed by the Director of Nursing and Administrator on 2/25/25. No changes indicated. - The Director of Nursing/Designee will educate the Unit Managers, Supervisors, administrator and Charge Nurses on the policies “Comprehensive care” completed 2/25/25. - The Director of Nursing/Designee will educate the Unit Managers, Supervisors, administrator and Charge Nurses on identification of residents who have splints, braces, casts, immobilizers or cervical collars. Including care plan initiation, appropriate measurable goals and interventions to ensure residents identified have limited range of motion or potential for in place. How facility plans to monitor performance to make sure the solutions are sustained: - To ascertain the effectiveness of the education an audit was developed. - DON/Designee will audit all new admission care plans with splint, brace, cast, immobilizer or cervical collar to ensure limited range of motion or potential for x 30 days then weekly x 2 months. - The Director of Nursing/Designee will perform chart Audit weekly on 10% of resident population care plans to ensure residents with splint, brace, cast, immobilizer or cervical collar to ensure limited range of motion or potential for was added to care plan x 3 months. Any discrepancies noted will be immediately rectified and re-education will be provided to appropriate licensed person by Director of Nursing/Designee. - The results of the Audit findings will be reported at monthly QAPI by the DON/designee for trending and analyzing for no less than 3 months or until the facility demonstrates sustained compliance as determined by committee.