Failure to Follow Admission Orders for C-Collar Care
Penalty
Summary
The facility failed to follow admission orders for a resident who returned from the hospital with a C2 neck fracture and an Aspen C-Collar. Upon readmission, the resident had orders for C-Collar care, including daily skin checks and the requirement to be laid flat in a bed for collar adjustments. However, staff placed the resident in a recliner instead of a bed, as the bed had been removed from the room. The recliner did not lay flat, and staff attempted to adjust the C-Collar while the resident was in the recliner, resulting in the resident experiencing pain and discomfort. No daily skin checks were performed as ordered, and the first adjustment of the C-Collar did not occur until several days after readmission. Staff interviews confirmed that the admission orders were not followed, and the facility's policy required review and implementation of all physician orders upon admission or readmission. The failure to follow these orders was acknowledged by facility leadership.