Failure to Obtain Written Physician Order and Improper Cervical Collar Positioning
Penalty
Summary
A deficiency occurred when a resident with dementia and a history of repeated falls experienced a fall after dinner and complained of right thigh pain. The Advanced Practice Registered Nurse (APRN) was notified and verbally ordered an x-ray, and the responsible party was informed that an x-ray would be completed. However, there was inconsistency in the documentation regarding whether a hip or femur x-ray was ordered, and no written physician order was entered into the electronic order management system as required by facility policy. The radiology report later indicated a femur x-ray was performed, but the lack of a written order created confusion about the intended diagnostic procedure. Another deficiency was identified involving a resident admitted with a cervical spine fracture and a physician's order to maintain a cervical collar at all times, except for care. Observations revealed that the resident's cervical collar was not appropriately positioned, with the chin piece on the resident's chin and the front piece floating above the chest. Nursing staff believed this was the correct placement, and one LPN stated she had not received the in-service training provided by physical therapy. The Director of Physical Therapy later confirmed the collar was not properly positioned and adjusted it accordingly. Documentation showed that staff education on collar alignment had been provided only to those present at the initial in-service. Review of the resident's care plan and nursing notes did not indicate prior issues with the resident moving the collar or behaviors affecting its alignment. Only after surveyor inquiry was the care plan updated to address resistance to care related to the cervical collar. Facility policy specified correct collar placement, but this was not consistently followed, resulting in improper positioning of the cervical collar for the resident.