F0726

D

Failure to Ensure Competent Staff Response to Refusal of Physician‑Ordered Knee Immobilizer During Transfer

Nora Springs, Iowa Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that nursing staff had and used appropriate competencies to explain the risks of not wearing a physician‑ordered knee immobilizer before transferring a resident, and to follow care plan and therapy directives regarding that immobilizer. The resident involved had intact cognition with a BIMS score of 15 and was care planned as dependent for transfers and ambulation, requiring assistance of two staff. The MDS and care plan documented multiple active diagnoses including fractures, osteoporosis, diabetes mellitus, morbid obesity, renal failure requiring dialysis, and an open surgical wound to the right knee. The care plan specified that a right knee immobilizer was to be on during transfers and ambulation, and that the resident was at risk for falls related to altered gait and balance, osteoporosis, prior fracture, obesity, renal failure, and an open wound with delayed healing. The care plan also identified a history of noncompliance with therapy recommendations and directed staff to educate the resident regarding potential risks and adverse effects of refusing recommendations, but it did not specify which staff were competent or responsible to provide that education.

Physician and therapy documentation directed that the resident should continue with a protective knee immobilizer at all times while weight‑bearing and that transfers and ambulation with two‑person assist and a walker required the immobilizer to be on. On the date of the incident, a CNA assisted the resident to transfer from a chair to a bed without the right knee immobilizer in place. The CNA acknowledged knowing that the resident needed the immobilizer for transfers and reported that the resident had refused to wear it. The CNA stated she offered limited education, telling the resident the immobilizer could be cleaned and would probably be better to have it on, but she did not notify the nurse of the refusal before proceeding with the transfer and verbalized she did not know when the immobilizer was required to be on. The RN on duty reported that she was only called to the room after the transfer attempt, not beforehand, and found the resident on the floor with legs bent backwards and without the knee immobilizer.

Following the transfer attempt without the immobilizer, the nurse’s assessment documented that the resident’s legs were bent backwards in a “W” position, the right knee wound was split open and actively bleeding, and the resident reported severe pain rated 10/10, was nearly hyperventilating, and could not move her legs or wiggle her toes. The incident report and subsequent documentation identified suspected bilateral broken legs, later described as bilateral closed fractures of the condyles of the tibial plateau and fibulae. Progress notes lacked documentation that the resident had refused the immobilizer or that staff had provided education on the potential risks and adverse effects of refusing it. Review of the CNA’s personnel file showed orientation and skills checklists for general tasks such as ambulation, transfers, use of gait belts, and splints/braces, but the skills evaluation lacked competency elements for alerting the nurse regarding refusal of immobilizers or appliances and lacked a facilitator signature. The facility’s transfer policy directed staff to transfer residents according to the care plan and to notify the nurse and document changes in condition, but it did not address immobilizers/appliances or specify who was responsible for education when such devices were refused. The facility also lacked a policy for training or competency of staff specific to immobilizers and appliances.