Failure to Apply Ordered Brace and Offloading Boot
Penalty
Summary
The facility failed to apply a brace/splint and an offloading boot to a resident as ordered by the provider and outlined in the resident's care plan. The resident, who had a history of respiratory failure, hemiplegia, and hemiparesis following a stroke, was observed on multiple occasions without the prescribed brace/splint or offloading boot in place. Interviews with the resident confirmed that they had not worn the devices recently and could not recall the last time they were used. The devices were not visible in the resident's room, and staff were initially unaware of the requirement for their use, only locating the brace after being prompted. The offloading boot could not be found during the survey period. Review of the resident's treatment administration record (TAR) showed that staff documented the devices as being applied per provider orders, despite observations and interviews indicating otherwise. The care plan and Kardex both specified the need for the brace and offloading boot, with interventions for their use when in bed or in a wheelchair. Staff interviews revealed a lack of awareness of the orders and care plan requirements, and the Director of Nursing Services confirmed that provider orders and care plans were not followed, and refusals were not documented as required.