F0684

D

Failure to Implement and Document Physician Order for Protective Helmet Use

Phoenix, Arizona Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and document a physician’s order for a resident to wear a protective helmet when out of bed. The resident was admitted with epilepsy, traumatic brain injury with brain compression and herniation, anxiety disorder, mood disorder, and major depressive disorder. A care plan focus initiated in early June 2023 identified an ADL self-care performance deficit related to activity intolerance, fatigue, confusion, and TBI, and included the intervention for the resident to wear a helmet out of bed. An active order dated June 6, 2023, and subsequent physician progress notes, including one dated January 9, 2026, directed that the resident wear a helmet when out of bed. A quarterly therapy screen and a quarterly MDS assessment showed no indication that the resident refused the helmet or that its use had been discontinued, and the MDS documented no rejection of necessary care in the seven days prior to that assessment.

Despite these orders and care plan interventions, surveyor observations over multiple days showed the resident repeatedly out of bed and ambulating without the helmet. On the first survey day at 9:00 AM, the resident was observed standing in his room without a helmet, while the helmet was on the nightstand under a wall sign stating “HELMET ON AT ALL TIMES OUT OF BED.” The resident reported that staff had helped him apply the helmet in the past. Shortly thereafter, a nurse entered to administer medications and did not assist with helmet application, and the resident was observed walking out of the room without the helmet. On subsequent days, the resident was observed in the activities room, in the dining room, and walking out of the dining room without the helmet. During an interview, the resident described the extent of his traumatic brain injury, stated he needed to be careful with ambulation due to risk of re-injury, acknowledged awareness of the helmet signage, and stated that staff assisted him with helmet application when needed.

The medical record lacked documentation that the helmet order was being implemented and lacked documentation of any refusals by the resident. An LPN who provided care to the resident stated she was unsure why the resident required a helmet, had not seen him wear it, and was unaware of the helmet order or the signage until it was pointed out; she confirmed that refusals of treatment should be documented on the MAR/TAR and communicated to the charge nurse, but could not locate a helmet treatment on the MAR/TAR. A CNA reported that the resident used to wear the helmet more frequently when first admitted but could not say why he stopped and assumed therapy had discontinued the order, though she had not been informed of any change. Later, the helmet signage in the resident’s room was found removed, and the charge nurse stated she did not know why it was taken down and believed therapy would discontinue such an order, yet there was no documentation of discontinuation in the record.

The director of rehabilitation stated that therapy had assessed and educated the resident on helmet use, including modifications to make it easier to don and doff, and that the resident was discharged from therapy with the expectation that helmet use out of bed would continue and that floor staff would cue and assist as needed. She stated that any caretaker could apply the helmet and that discontinuation of such an appliance would be documented in the chart, which was not evident for this resident. The interim DON confirmed that the active order for helmet use out of bed had not been discontinued and that facility expectations were to follow physician orders as written, update care plans as needed, and document completion of orders and refusals so providers are aware. Facility policies on documenting and charting and on physician orders required complete documentation of care and accurate implementation and transcription of treatment orders into the eMAR/eTAR. The lack of implementation and documentation of the helmet order, and absence of documented refusals or discontinuation, constituted the deficiency.