Failure to Obtain Physician's Order for Orthotic Device Use
Penalty
Summary
The facility failed to obtain a physician's order for the use of an orthotic device, specifically an immobilizer, for one resident who was admitted with a left femur fracture, diabetes, and muscle weakness. Upon admission, the resident was noted to have an immobilizer on the left lower extremity, as documented in the Braden Scale Assessment and multiple skilled nursing notes over several days. Despite the continued use of the immobilizer, there was no physician's order in the medical record authorizing its use during this period. Interviews with various staff members, including CNAs, the Wound Care Nurse, the Rehabilitation Director, and a PTA, confirmed that the resident was admitted with the immobilizer in place and that it was used for several days following admission. The resident's daughter also confirmed the use of the immobilizer upon admission and its discontinuation after several days. The facility's policy required that splints and braces be provided in accordance with professional standards and as ordered by a practitioner, but this was not followed in the resident's case. The Director of Nursing acknowledged that the nursing staff did not obtain a physician's order for the immobilizer and confirmed the deficiency. The lack of a physician's order for the orthotic device was identified through facility policy review, medical record review, documentation review, and staff and family interviews, establishing that the required protocol for orthotic device use was not followed for this resident.