Improper Application of TLSO Brace for Resident
Penalty
Summary
The facility failed to ensure that Resident #57 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #57, who had a diagnosis of osteoporosis with a current pathological fracture of vertebrae, was observed wearing a thoracolumbar sacral orthosis (TLSO) brace incorrectly. The comprehensive care plan did not address interventions for the TLSO brace, and staff involved in the resident's care were not adequately educated on the application of the brace. Observations revealed that the TLSO brace was consistently positioned incorrectly on the resident, resting on their breasts instead of fitting around their lower torso and abdomen. Interviews with staff, including certified nurse aides and therapy personnel, indicated a lack of proper training and understanding of how to apply the brace correctly. Although some staff recalled initial education on the brace when the resident was first admitted, there was no documentation or sign-in sheet to confirm which staff received training, and many staff members reported not being educated on the brace's application. The facility's failure to document and implement a comprehensive care plan for the TLSO brace, along with inadequate staff training, led to the resident wearing the brace incorrectly. This deficiency was compounded by the absence of physician orders for the brace and a lack of consistent monitoring and documentation of its use. The Director of Nursing and other staff members acknowledged the issue but did not take effective action to address the incorrect fit and frequent removal of the brace by the resident.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 The effected resident (#57) order for thoracolumbar sacral orthosis brace was updated by the physician. The resident’s care plan was updated to reflect the brace and interventions, and monitoring related. The resident had a follow-up with orthopedics and her brace was discontinued on 3/7/2025. All other residents with DME records were reviewed to ensure that they had proper physician order, and care plan included interventions and monitoring for the DME. No other residents were identified. Facility-wide training regarding TLSE DME was initiated on 3/3/2025. All clinical staff to receive training on DME specific to braces. Upon identifying a new brace, Therapy will initiate training and systematically ensure clinical staff receive training prior to caring for resident. The Director of Nursing will review records of residents with DME on a bimonthly basis to ensure that there is an order, and care plan reflects DME and any intentions and monitoring is included in the record. The audit tool and findings will be reviewed quarterly with the Quality Assurance and Performance Improvement committee. The findings will be monitored for 1 year to ensure compliance. Date of Correction: 3/7/2025 Person Responsible: Director of Nursing