F0688

D

Failure to Provide and Maintain Prescribed Cervical Collars and Splints for Two Residents

Fort Wayne, Indiana Survey Completed on 03-31-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide and maintain prescribed cervical collars and a mechanical back/cervical splint for two residents with significant neurological and musculoskeletal impairments. For one resident with a history of cerebral infarction, right middle cerebral artery occlusion, and left-sided hemiplegia/hemiparesis, surveyors repeatedly observed her in bed without the ordered soft cervical collar in place, despite a physician’s order that she wear the collar while in bed and for all meals for neck contracture management. The collar was seen on the bedside stand during one observation, and the resident’s care plan and CNA Kardex contained no instructions regarding use or refusal of the collar. The NP’s earlier progress note documented that the resident liked wearing the collar and wanted to wear it more frequently than ordered, and there were no subsequent notes documenting refusal or discontinuation.

Staff interviews further showed inconsistent understanding and implementation of the collar order for this resident. A CNA reported believing the collar had been discontinued after a trial for meals only, stating it was unsuccessful and that she understood it was no longer in use. The DON stated the collar had been used when the resident was eating meals consistently, but that it was not being used because the resident was now being offered food for pleasure only and was expected to receive a feeding tube. The DON also stated the collar was in the laundry because it was dirty and acknowledged that refusals should have been documented and that frequent refusals should have triggered re-evaluation of the device. The Director of Therapy confirmed the collar had been implemented for a right-sided neck contracture and that the resident initially wanted to wear it more often, and indicated that documentation of refusals was the responsibility of nursing. The facility’s policy on braces and assistive devices required documentation of refusals, follow-up actions, and care plan updates addressing device type, application instructions, monitoring guidelines, and specific risks, which were not reflected in the record.

For a second resident with diagnoses including unspecified intracranial injury, left-sided hemiplegia, and traumatic subarachnoid hemorrhage, surveyors repeatedly observed her during meals with her head leaning to the left, without the prescribed mechanical back/cervical splint in place, and with full or covered meal trays that she was not eating. Her care plan identified an ADL self-performance deficit and included an intervention for application of a cervical/back splint during meals and removal afterward. Physician orders directed that she wear a cervical brace during all meals, angled approximately 30 degrees in extension with a towel under the brace. However, the most recent MDS did not indicate use of splints or braces, and staff interviews revealed ongoing problems with the brace’s fit and function that were not effectively addressed.

CNAs reported that the resident should have had the brace on but that her head repeatedly slipped out of it, even after attempts to reposition her and reapply the brace, and one CNA stated she was unsure whether the NP or therapy had been notified. Another CNA described the Velcro on the brace releasing and the resident sliding in her seat so that the brace could not support her head, and indicated she had not been instructed on alternative interventions if the brace was ineffective and was unaware of any notification to NP or therapy. The Director of Therapy stated that therapy was initially responsible for the brace and that, after discharge, restorative nursing managed issues, with therapy performing screenings every three months; she acknowledged awareness that the Velcro continued to come undone but did not describe additional actions to ensure the brace was safe and properly fitting. The restorative nurse reported that Velcro had been replaced earlier in the month and that staff had not reported ongoing issues. The DOT later stated that the resident had been missed for a scheduled reassessment that should have occurred approximately three months after the last assessment and that she was on a list for reevaluation while therapy awaited an order. The facility’s policy required assessment of braces and assistive devices on admission, with changes in condition, and periodically as part of the care plan process, with nursing staff reporting changes in mobility or tolerance and reassessment quarterly with MDS review, which was not consistently carried out for this resident.