F0656

D

Failure to Care Plan and Implement NWB and Immobilizer Orders for Orthopedic Resident

National City, California Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The facility failed to develop and implement an appropriate care plan and admission orders to ensure safety interventions were in place for a resident with a periprosthetic fracture around an internal prosthetic right knee joint. The resident was admitted with hospital discharge instructions specifying non-weightbearing (NWB) status on the right lower extremity and continuous use of a right knee immobilizer locked in extension, including for bed-to-chair transfers. Despite these orders, the facility did not initiate or revise the resident’s care plan to include NWB status or immobilizer use upon admission, and these orders were not carried over to the physician’s order sheet at the time of admission. The leg brace order was not entered until later in the month, and the NWB and immobilizer orders were only documented several days after admission.

During interviews, multiple staff members, including CNAs and a restorative nursing assistant, reported they were unaware of the resident’s need for a splint/immobilizer or his weightbearing status, even though a sign in the resident’s room indicated that the right knee immobilizer was to be on at all times. The resident himself stated that his immobilizer needed to be on at all times and that he participated in therapy exercises. A licensed nurse confirmed that the care plan had not been initiated or revised for NWB orders at admission and that immobilizer use was not in place at that time. The DON stated that the immobilizer and plan of care should have included the resident’s weightbearing status and that this information should have been communicated to all staff. The facility was unable to provide a policy and procedure for comprehensive care plans.