Inaccurate Documentation of Cervical Collar Use
Penalty
Summary
A deficiency was identified when the facility failed to maintain accurate medical records for a resident who was required to wear an Aspen cervical collar at all times following a fall that resulted in a head injury and cervical fracture. The physician's order specified that the collar should remain in place at all times, with removal only permitted for skin checks and ADL care, and to be replaced every shift. However, during multiple observations, the resident was not wearing the cervical collar as ordered. Further review of the resident's medical records revealed inconsistencies in documentation. Although the resident had refused to wear the cervical collar on several occasions, nursing staff signed the Treatment Administration Record (TAR) indicating the collar was worn on those days, as well as on days when the resident was observed without the collar. The Unit Manager confirmed that the nurses were not accurately documenting the resident's refusals on the TAR, despite the refusals being noted in progress notes.