COSTA MESA, CA - A post-acute care facility allowed a resident recovering from a serious vehicular accident to go without a medically ordered cervical collar for weeks, despite physician instructions requiring the protective device be worn at all times, according to a state inspection conducted in June 2024.
Failure to Implement Critical Spinal Protection Protocol
Inspectors from the California Department of Public Health documented that Mesa Verde Post Acute Care Center failed to ensure a resident, identified as Resident 17, wore a cervical collar as prescribed by a physician following spinal injuries sustained when the resident was struck by a car while in a wheelchair. The medical device, designed to stabilize the neck and prevent further injury to the cervical spine, was consistently found sitting unused on the resident's bedside table rather than being properly applied.
During an initial facility tour on June 3, 2024, at 8:45 a.m., surveyors observed the resident lying in bed without the cervical collar. The protective device was instead sitting atop the resident's bedside drawer. When asked about the injury, the resident explained he had been hit by a car a couple of weeks earlier while in his wheelchair.
The physician's order, dated April 12, 2024, specifically directed that the cervical collar be applied "at all times" and that a TLSO (thoracolumbosacral orthosis, a type of back brace) be used during out-of-bed activities or when the head of the bed was elevated greater than 30 degrees. Medical records confirmed the resident had the mental capacity to understand and make his own medical decisions, yet staff failed to address the situation appropriately.
Medical Significance of Cervical Collar Non-Compliance
Cervical collars serve a critical function in protecting the delicate structures of the neck following trauma or surgical intervention to the cervical spine. These devices limit range of motion in the neck, preventing flexion, extension, and rotation that could potentially displace healing vertebrae, compress the spinal cord, or damage nerve roots.
Following significant cervical spine trauma—such as that sustained in a vehicular accident—the spinal column requires immobilization during the healing process. Movement of unstable vertebrae can result in compression of the spinal cord, potentially causing permanent neurological damage including paralysis, loss of sensation, or impaired respiratory function. In severe cases, displacement of cervical vertebrae can be life-threatening.
The cervical spine contains seven vertebrae that house and protect the spinal cord as it exits the skull and travels down the neck. This region is particularly vulnerable to injury because of its mobility and the relatively small size of the vertebral bodies. When injury occurs, strict immobilization protocols become essential to prevent secondary injury during the healing phase, which typically lasts six to twelve weeks depending on the severity of the trauma.
Physicians prescribe cervical collars with specific wearing instructions based on the nature and severity of spinal injuries. When orders specify the collar should be worn "at all times," this reflects the physician's clinical judgment that the injury poses sufficient risk that even minor neck movements during daily activities could compromise healing or cause additional damage.
Systemic Breakdown in Care Implementation
The inspection revealed that the failure to ensure proper cervical collar use represented a breakdown at multiple levels of care delivery. On June 4, 2024, at 11:38 a.m., surveyors again observed the resident lying in bed without the cervical collar in place, confirming the issue was ongoing rather than an isolated incident.
Interviews with multiple staff members revealed concerning gaps in awareness and communication regarding the resident's medical needs. A restorative nursing assistant (RNA 1) who was actively providing services to the resident stated during a June 4 interview at 3:50 p.m. that she had never been instructed to apply either the cervical collar or back brace to the resident. This indicated that critical physician orders were not being properly communicated to the direct care staff responsible for implementing them.
A licensed vocational nurse (LVN 5) interviewed at 4:00 p.m. that same day verified she had never seen the resident wearing either the cervical collar or back brace and had never attempted to apply them according to the physician's orders. The nurse stated she was not aware of why the resident was not using the cervical collar, revealing a fundamental breakdown in care plan awareness among nursing staff.
During an early morning observation on June 5, 2024, at 5:28 a.m., another licensed vocational nurse (LVN 4) was conducting rounds. When asked about the resident's use of the cervical collar and back brace, the nurse stated the resident did not use either device and that she did not know if the resident needed them. The nurse was uncertain whether the resident had refused to wear the cervical collar.
Absence of Care Plan Documentation and Physician Communication
Review of the resident's care plan revealed another significant deficiency: the plan failed to address the application of the cervical collar, the use of the TLSO brace when out of bed, or any issues with non-compliance. Comprehensive care plans serve as the roadmap for all aspects of resident care, ensuring that every staff member across all shifts understands the specific interventions required for each individual.
The facility's Director of Rehabilitation (DOR) acknowledged during a June 4 interview at 3:34 p.m. that the resident did not wear the cervical collar as ordered by the physician. The DOR stated the resident received both a cervical collar and back brace but was non-compliant with wearing both devices. However, documentation showed the facility had not appropriately addressed this non-compliance.
The DOR indicated that the resident should have had a follow-up appointment with an orthopedic specialist and that only an orthopedic specialist could address the cervical collar order. This statement reflected a misunderstanding of the facility's responsibilities. While specialist consultation is important, the existing physician's order remained valid and required implementation until modified by the ordering physician or specialist.
When the Director of Nursing (DON) and MDS coordinator were interviewed on June 5 at 5:30 a.m., the DON stated the resident had been refusing to wear the cervical collar and claimed the physician was aware of this refusal. However, the DON was unable to provide documented evidence that either the physician or orthopedic specialist had been notified about the resident's refusal. The MDS Coordinator confirmed the resident had not been seen by an orthopedic specialist during his entire admission to the facility, despite the DOR's earlier statement that such follow-up was necessary.
Standard Protocols for Addressing Medical Device Refusal
When a resident refuses a medically necessary treatment or device, established healthcare protocols require specific actions. Staff must first assess whether the resident fully understands the medical necessity of the intervention and the potential consequences of refusal. Education should be provided in terms the resident can comprehend, and alternative approaches should be explored when possible.
If a resident with decision-making capacity continues to refuse treatment, this constitutes an informed refusal that must be documented thoroughly. The documentation should include what information was provided to the resident, the resident's stated reasons for refusal, and the potential risks explained to the resident. The ordering physician must be notified promptly so they can discuss the situation with the resident directly, reassess the medical necessity, consider alternatives, or modify orders as appropriate.
The facility should also convene an interdisciplinary team meeting to develop strategies for encouraging compliance while respecting the resident's autonomy. This might include addressing comfort issues with the device, adjusting wearing schedules if medically permissible, or involving family members in encouraging adherence to medical recommendations.
None of these standard protocols appeared to have been followed systematically at Mesa Verde Post Acute Care Center. The lack of documentation regarding physician notification, absence of care plan interventions addressing the non-compliance, and staff unfamiliarity with the resident's medical needs all indicated the facility failed to implement appropriate processes.
Additional Issues Identified
The inspection also revealed the facility's own educational materials contradicted the approach taken with this resident. A facility document titled "Your Path to Recovery After Cervical Spine Surgery," revised in November 2015, explicitly stated that when a cervical collar is ordered, it typically should be worn at all times and is used to provide support and limit movement of the neck. The document noted that wearing the collar is at the surgeon's discretion, emphasizing the importance of following specific physician instructions—precisely what had not occurred in this case.
The failure affected multiple aspects of care coordination. Restorative nursing services were being provided to the resident without proper implementation of physician orders for spinal protection. Nursing staff across multiple shifts demonstrated lack of awareness regarding critical medical interventions. The rehabilitation department acknowledged non-compliance but failed to implement effective interventions or ensure proper medical follow-up.
The inspection classified this deficiency as causing "minimal harm or potential for actual harm" and noted it affected "few" residents. However, the potential consequences of allowing a resident with cervical spine injuries to remain without ordered immobilization could have been severe, including permanent neurological damage or paralysis.
This case illustrates the critical importance of systematic processes for implementing physician orders, communicating care requirements to all staff members, documenting and addressing treatment refusals, and ensuring appropriate medical follow-up when residents decline recommended interventions. The convergence of multiple system failures—from care planning to staff education to physician communication—created an environment where a vulnerable resident's spinal injury recovery was placed at unnecessary risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mesa Verde Post Acute Care Center from 2024-06-06 including all violations, facility responses, and corrective action plans.
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