Failure to Provide Physician-Ordered Neck Brace
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency occurred when a resident with a type 2 odontoid fracture, admitted in October 2025, did not receive a physician-ordered neck brace as required. The physician's order specified that the neck brace should be applied at all times, but record review showed that the brace was not available and not applied during multiple shifts over two consecutive days. Documentation from the Treatment Administration Record confirmed the absence of the neck brace during these periods, and a Physical Therapy progress note indicated that the brace was not on the resident and could not be located by nursing staff. During an interview, the Director of Nursing Services acknowledged that her expectation was for the neck brace to be applied as ordered.