Failure to Provide Accurate Orthotic Care and Honest Documentation After Ankle Fracture
Penalty
Summary
Nursing staff failed to provide care and services that met professional standards of quality for a resident who sustained a fracture of the distal left tibia and fibula after sliding from a sit/stand lift during a transfer. The resident, who had cerebral palsy, a history of deep vein thrombosis of the left lower extremity, muscle weakness, hypertension, hyperlipidemia, major depressive disorder, osteitis, and a lumbar compression fracture, was cognitively intact but dependent on staff for transfers. Following the fall, the resident was evaluated in the emergency department, where a short leg fiberglass splint was applied to the left lower extremity and the resident was returned to the facility with the splint in place and non‑weight‑bearing instructions. Despite this, the resident’s care plan and Treatment Administration Record (TAR) documented that the resident had a Controlled Ankle Motion (CAM) boot on the left lower extremity when out of bed, with orders to apply skin prep to the left heel each shift and to remove the CAM boot as tolerated to assess skin for breakdown, swelling, or infection. These treatments were signed off as completed by licensed nurses on all shifts from early January through early February, even though the resident was never fitted with and never had a CAM boot. Orthopedic consultations later confirmed that the resident was to keep the splint on the left lower extremity and remain non‑weight‑bearing, and surveyor observation showed the resident wearing only a splint with an Ace wrap, with no CAM boot available. Interviews with the resident and multiple nurses revealed that staff knew the resident had a splint with an Ace wrap, not a CAM boot, and that the splint had not been removed. One nurse admitted she did not know what a CAM boot was, acknowledged that the resident did not have one, and stated she had not applied skin prep to the left heel or removed a CAM boot, despite having signed the TAR indicating those treatments were done. Other nurses and the DON consistently stated that the resident returned from the hospital with a splint, not a CAM boot, and that the TAR and treatment orders were not updated to reflect the actual orthotic device and required nursing care. This resulted in documentation of care and treatments that could not have been performed as ordered, and a failure to systematically assess and implement the correct prescribed medical regimen in accordance with professional standards.
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