Failure to Obtain Physician Orders for Immobilizer at Admission
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document physician orders for a resident's immediate care needs at the time of admission. The resident, an older adult female with a history of bilateral distal femur fractures, hypertension, multiple sclerosis, and paraplegia, was admitted with a right knee immobilizer in place as per hospital discharge instructions. Despite this, there was no physician order for the immobilizer documented in the facility's records upon admission or in subsequent physician order reports. Multiple staff interviews revealed that the admitting nurse did not clarify or transcribe the order for the immobilizer, and nurse managers did not verify the presence or need for the device during the admission process. Several staff members, including LVNs, CNAs, the DON, and the ADON, were either unaware of the immobilizer or did not recall seeing an order for it. The lack of a documented order led to confusion among staff regarding the application and continued use of the immobilizer, with some staff unaware that the resident required it for her fracture. Record reviews confirmed that the immobilizer was noted in the hospital discharge summary and initial progress notes, but this information was not carried over into the facility's physician orders or care plan interventions at the time of admission. The absence of a physician order for the immobilizer resulted in inconsistent care and the eventual discontinuation of its use, despite the resident's ongoing need for stabilization of her fracture.