F0656

D

Failure to Care Plan for Knee Immobilizer Use and Monitoring

Charlotte, North Carolina Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The facility failed to develop an individualized comprehensive care plan that included immobilizer care for a resident with a right upper tibia fracture. The resident was admitted with a physician’s order for a right lower extremity knee immobilizer to be worn at all times, removed only for skin checks and hygiene, with the extremity maintained in extension. The order also required staff to document skin integrity every morning and at bedtime and to notify the provider if the skin was not intact. Record review showed that the comprehensive care plan dated the same day as the order contained no goals or interventions related to the right knee immobilizer, despite the resident being cognitively intact per the admission MDS.

During interviews, the nurse assigned to the resident stated she did not know if the resident was care planned for the knee immobilizer and acknowledged that the resident should have a care plan in place. The Unit Manager explained that, upon admission, the admitting nurse, MDS Coordinator, and DON review orthopedic orders to determine care needs and that anything related to the resident’s care should be reflected in the care plan; she was not aware the immobilizer was omitted and did not know how it was missed. The MDS Coordinator confirmed he develops care plans based on diagnoses, MDS triggers, medical records, and resident interviews, stated he did not recall seeing a knee immobilizer on the resident, and acknowledged that interventions for the immobilizer should have been included, calling its absence an oversight. The DON stated that the MDS Coordinator develops care plans that are reviewed by the interdisciplinary team and confirmed the knee immobilizer was a significant part of the resident’s care and should have been included in the comprehensive care plan.