Failure to Maintain Ordered Cervical Collar for Resident With C1–C2 Fracture
Penalty
Summary
The facility failed to ensure that a resident with a known C1–C2 cervical fracture had his cervical collar (C‑collar) in place as ordered. The resident’s face sheet documented a nondisplaced fracture of the first cervical vertebra, unspecified dementia, and a history of falls. Nursing progress notes indicated the resident was admitted with a C‑collar due to a traumatic closed C1 fracture, and physician orders dated March 4, 2026 directed that the C‑collar be on at all times. The resident’s care plan, initiated the same day, identified the need for a brace due to limitation in range of motion and C1 fracture, with an intervention to apply the brace per MD order. A CNA reported that on the day after admission, the resident had been in bed with the C‑collar on, but after hearing a noise and entering the room, he found the resident on the floor with the C‑collar off and lying on the opposite side of the bed near the dresser. The CNA acknowledged the resident was supposed to have the collar on at all times and was a high fall risk. A RN stated she was the nurse who sent the resident to the ED after the fall and confirmed that the resident did not have the C‑collar on when she assessed him, despite the order for continuous use due to prior fractures. EMS documentation showed staff last checked on the resident around 9:00 PM and found him on the floor about 50 minutes later, with paramedics noting a deformity of the right hip and stabilizing the hip with a blanket before transport. The EMS record did not show that the C‑collar was reapplied, provided to EMS, or that EMS was informed of the existing neck fracture before transport. The ED note later documented that the facility nurse reported a known closed C1–C2 neck fracture and that the patient arrived without a C‑collar, prompting the ED physician to apply an Aspen collar. A physical therapist stated it was the nursing department’s responsibility to ensure devices were placed and removed as ordered and noted that cognitively impaired residents may remove devices, requiring staff monitoring to ensure devices remain in place.
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