Failure to Implement and Document Physician-Ordered Toe Fracture Treatment
Penalty
Summary
A resident with multiple diagnoses, including disorders of bone density and muscle wasting, was admitted to the facility and later sustained an acute fracture of the left first toe, as confirmed by x-ray. The physician ordered the first toe to be taped to the second toe until an orthopedic consult, and the orthopedic specialist subsequently recommended buddy taping or splinting the toe for four to six weeks. However, there was no documentation indicating that the toe was taped as ordered, nor was there evidence that the orthopedic recommendations were transcribed into physician orders or followed after the consult. During observations and interviews, staff were unable to confirm if or when the resident's toes were taped, and the nurse did not transcribe the orthopedic recommendations into the resident's orders. The facility's policies required documentation of treatments and adherence to physician orders, but these were not followed in this case. The lack of documentation and failure to implement the prescribed treatment had the potential for the resident's injury to worsen.
Plan Of Correction
Immediate corrective action: Following observations on 6/20/2025, resident 1's toe was checked and buddy taped. Treatment records were updated, and staff in-serviced to ensure checking and taping were completed per the order summary report. Identifying other potentially affected: On 6/23/2025, the DON and Medical Records conducted a random review of three residents having treatment orders and observations. Audits and physical observation revealed successful evidence of completion. No additional concerns were noted. Measures for systemic change: Between the dates of 6/23/2025 and 6/27/2025, the DON provided in-services to licensed nurses regarding carrying out physician orders and proper completion of buddy taping and documentation of doing so for Resident 1's left toes. Monitoring for compliance: The DON and/or RN Supervisor will visually check Resident 1's toe for proper buddy taping regularly until follow-up physician orders discontinue the need. Successful completion of items above: