Failure to Obtain Physician Order for Knee Immobilizer at Admission
Penalty
Summary
The facility failed to ensure that a physician's order was obtained for a knee immobilizer at the time of admission for a female resident with a recent right patella fracture. Despite hospital records indicating non-operative treatment with a knee immobilizer and weight bearing as tolerated, and a physician progress note stating the brace should be worn at all times, there was no evidence in the facility's records of an order for the knee immobilizer upon admission. The care plan also did not address the use of the knee immobilizer. Multiple observations confirmed the resident was wearing the knee immobilizer during her stay, and interviews with staff revealed that the immobilizer was applied based on verbal instructions rather than a documented physician order. The admitting nurse was responsible for entering orders from the hospital, but this was not completed, and subsequent order reconciliation did not identify the omission. Facility policy required physician orders to be reviewed and approved, but this process failed to ensure the necessary order was in place for the resident's immediate care needs.