Inaccurate Documentation of Knee Immobilizer in Medical Record
Penalty
Summary
The facility failed to maintain complete, accurate, readily accessible, and systematically organized medical records for a resident with a right knee immobilizer. The resident was admitted with a diagnosis of aftercare for an orthopedic encounter and had a physician’s order dated 2/18/2026 for a right knee immobilizer to restrict movement of the right knee. The quarterly MDS documented that the resident was an older female admitted for long-term care with ADL support needs, a fragile right knee capable of dislocation, and supported with an immobilizer, and the resident had a BIMS score of 13/15 indicating no cognitive impairment. Nursing progress notes by an LVN on 2/2/2026 documented that the resident had a right knee immobilizer and that there were no concerns at that time. Despite this, weekly skin assessments completed by LVN G on 2/12/2026, 2/19/2026, and 2/26/2026 documented that the resident did not have a brace, even though the resident was wearing a right knee brace. During interviews, the resident reported having a bad right knee that had given out, leading to a fall at home, subsequent hospitalization, and an orthopedic procedure after which an immobilizer was provided to prevent dislocation. CNA B confirmed that the resident had a right knee immobilizer, and LVN G acknowledged recognizing the brace during initial assessment and stated he was unaware he had documented “no brace” on some weekly skin assessments, describing this as an oversight that could result in an inaccurate record. The DON stated the expectation that all staff documentation be accurate, and the facility’s medical records policy stated that every resident must have an accurate record.
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