Failure to Obtain Physician Orders for Orthopedic Devices
Penalty
Summary
A deficiency occurred when a resident with a history of multiple fractures, including an unspecified fracture of the third thoracic vertebra and muscle weakness, was admitted to the facility with a back brace and bilateral foot protectors. The resident was cognitively intact and required the back brace when out of bed and foot protectors while in bed, as confirmed by both the resident and staff. Despite this, the resident's care plan did not address the use of these devices, and there were no physician orders for either the back brace or the foot protectors in the resident's medical record at the time of review. Staff interviews revealed that both CNAs and nurses were aware of the resident's need for the back brace and foot protectors, and assisted the resident with their use. However, staff were unsure about the existence of physician orders for these devices. The nurse assigned to the resident and the unit manager both confirmed that physician orders should have been present, but were not found in the system until the unit manager entered them during the survey process. The Director of Nursing also confirmed that physician orders were required and that it was the responsibility of the admitting nurse and nurse management to ensure all necessary orders were obtained and documented. The facility's policy required that written and/or verbal orders for immediate care and needs, including treatment and routine care orders, be obtained upon admission to allow staff to provide essential care. The absence of physician orders for the back brace and foot protectors meant that staff did not have formal guidance for their use, which was inconsistent with professional standards of practice and the facility's own policies.