Care Plan Lacked Spinal Precautions and LSO Brace Interventions for Post-Lumbar Fusion Resident
Penalty
Summary
The facility failed to develop a care plan that addressed the specific needs of a resident who had undergone a lumbar fusion and required spinal precautions and the use of an LSO (lumbosacral orthosis) brace when out of bed. Medical record review showed that the resident was admitted with diagnoses including spinal stenosis and lumbar fusion, and both the history and physical examination and therapy notes indicated the need for spinal precautions and the LSO brace. A physician's order was also present for the use of the LSO brace when the resident was out of bed. However, the resident's care plan did not include interventions for spinal precautions or the use of the LSO brace. Interviews with OT and PT staff confirmed that the resident required spinal precautions and the LSO brace, and they acknowledged that these interventions were not included in the care plan. Observations and interviews with CNAs revealed inconsistent understanding and implementation of the required precautions, with one CNA stating that no other precautions were needed during transfers or in-bed mobility, and another CNA indicating no special precautions were necessary during transfers. The DON and Administrator were made aware of and acknowledged these findings.