Failure to Care Plan and Implement Care for Physician-Ordered Knee Immobilizer
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident’s physician-prescribed right knee immobilizer. The resident was admitted with a diagnosis of aftercare for an orthopedic encounter and had a fragile right knee capable of dislocation, supported with an immobilizer. The quarterly MDS showed the resident was cognitively intact with a BIMS score of 13 and required ADL support. Physician orders dated 2/18/2026 prescribed a right knee immobilizer to restrict movement of the right knee, but the care plan dated 3/18/2026 contained no focus, goals, or interventions related to the immobilizer, despite the facility’s policy requiring a comprehensive person-centered care plan and a baseline care plan within 48 hours of admission. Nursing documentation on admission noted the presence of the right knee immobilizer, but there were no subsequent orders or care plan interventions detailing how staff should manage or care for the device. During interviews, the resident reported that staff sometimes provided bed baths and other times wrapped the knee in plastic and used a shower bed, but that no staff had removed the brace to check her skin, removed the brace for care, or washed the brace. The resident stated she did not believe staff knew how to care for the brace and was reluctant to allow them to remove or check it. She reported becoming concerned when the brace developed a foul smell and stated that her representative eventually brought a brace from home and replaced the dirty, smelly brace. A CNA reported having no instructions on the CNA care plan regarding how to provide ADL care for the brace and stated she relied on common sense, not removing the brace and wrapping it to keep it dry during bathing. The attending physician stated he expected the immobilizer to be removed periodically for skin breakdown prevention, with the knee kept flat and non–weight bearing during hygiene care, and noted that no one from the facility had called for order clarification. A physician assistant stated that when a resident is admitted with an orthotic device, staff should report to the physician to obtain orders for application, removal, and daily care, and that this had not occurred. The DON acknowledged that the admitting LVN documented the immobilizer, but there were no orders or care plan interventions for it, and stated she expected the ADON to have obtained care instruction orders and updated the care plan, which had not been done.
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