**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to insure the services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (Resident #1) of seven Based on medical record review and interview, the facility failed to notify the Physician when Resident #68 incurred substantial injury related to a fall, had a decline in status, and needed treatment alterations regarding a [MEDICATION NAME] Lumbar Spinal Orthopedic (TLSO) brace. Failure for the facility to notify the Physician on 11/1/17 resulted in Resident #68 developing an axillae pressure ulcer while experiencing pain from the TLSO brace (HARM).

The findings included: Medical record review revealed Resident #68 sustained an initial fall on 8/6/17 at 11:01 AM which was unwitnessed with no injury reported and no interventions added to the Care Plan. Further review of the medical record revealed Resident #68 incurred a second fall on 10/31/17 at 2:50 PM which was unwitnessed with injury. Resident #68 was sent out to the Emergency Department and transferred to a Level II hospital equipped to care for such injury. Further review of the medical record revealed the Attending Physician was not notified of Resident #68’s injury which was: multiple acute fractures of the T1, T2, T12, L1, and fractures of the right anterior fourth through the seventh ribs near the costochondral junction.

Medical record review revealed Resident #68 incurred a substantial decline in physical and mental status as discussed during the Care Plan meeting on 11/13/17 with Resident’s family present. Further review of the medical record revealed a timeframe of 14 days passing before Physician intervention when the TLSO was discontinued along with other additional orders.

Interview with the Wound Care Nurse on 12/20/17 at 7:55 AM in the 200 Hall Nurses Station revealed .It was the brace that caused his wound, it was not properly fitting and rubbed him .

Interview with Licensed Practical Nurse (LPN) #3 on 12/20/17 at 10:41 AM on the 200 Hall Nurses Station revealed .Resident #68 is scheduled to have weekly skin assessments . Further interview with LPN #3 confirmed the facility failed to follow the care plan to complete weekly skin assessments. A total of 26 skin assessments were missed during 11/1/17 through 11/14/17 when pressure ulcer under armpit was found.

Interview with the Director of Nursing (DON) on 12/20/17 at 4:30 PM in her office confirmed, Resident #68 was sent to the hospital after the fall dated 10/31/17 and returned on 11/1/17 with a [DIAGNOSES REDACTED]. Resident #68 returned on 11/1/17 with a [MEDICATION NAME] Lumbar Spinal Brace in place.

Interview with the DON on 12/20/17 at 4:30 PM revealed Resident #68 .came back with the brace on . Further interview confirmed .we were trying to get his orders clarified . When asked what is a reasonable time period to get Physicians orders clarified the DON responded, .as quick as possible . The DON confirmed the facility failed to adequately notify the Physician and obtain instructions for the [MEDICATION NAME] Lumbar Spinal Orthopedic brace and continued use of the brace which resulted in a pressure ulcer to Resident #68 (HARM).

THE ADVERTISEMENT IS NEITHER AUTHORIZED NOR ENDORSED BY THE DEPARTMENT OF HEALTH, DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES, OR ANY OTHER GOVERNMENTAL AGENCY