Failure to Care Plan for Cervical Fracture and Aspen Collar Use
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a person-centered care plan addressing a resident’s C6 cervical fracture and ordered Aspen collar use. The resident, a male admitted with diagnoses including a displaced fracture of the sixth cervical vertebra, syncope, collapse, and weakness, had a history and physical dated 12/6/25 documenting a syncopal episode with a fall, head strike, neck pain, and a scalp laceration requiring sutures. MRI showed an anterior superior vertebral body fracture, and he was stabilized in an Aspen collar with a recommendation for continued collar use and follow-up imaging. An after-visit summary dated 12/12/25 directed that the Aspen collar be worn at all times, and a provider note dated 12/15/25 confirmed the C6 fracture and Aspen collar, noting the resident was seen heading to therapy in the collar. Despite these documented orders and clinical findings, review of the resident’s care plan revealed no care plan related to the cervical fracture or the use of the Aspen collar. Interdisciplinary documentation on 12/16/25 described the resident as alert and oriented with some confusion, continuously removing the Aspen collar despite education to keep it in place per provider orders, and being unsteady, requiring assistance of two for bed mobility, transfers, and ambulation. During interviews, the Infection Prevention Manager/RN and the DON both confirmed there was no care plan in place for the C6 fracture or Aspen collar and stated that a care plan should have been created at admission by the assigned clinical care coordinator/RN responsible for the resident’s unit.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.