The devices were supposed to be worn at all times, removed only for skin checks and hygiene care. Instead, they remained hidden away at Brooklyn Center for Rehab and Residential Health Care until a rehabilitation director discovered them during a November inspection.
Multiple nursing assistants told inspectors the same story. They used to see medical device instructions when signing off on tasks in the electronic system. Not anymore.
"They are no longer seeing those devices in the electronic medical record, and they do not know how to check the instructions when documenting tasks performed," according to the inspection report.
The charge nurse on the unit, Licensed Practical Nurse #4, admitted she hadn't seen Resident #2 wearing any devices "because the Certified Nursing Assistant had not been applying it." She said the instructions were supposed to be visible to nursing assistants in the Kardex system so they would know what needed to be done.
She wasn't aware the assistants couldn't view the care plan instructions.
The Rehabilitation Director learned about the missing devices only when informed during the November 3 inspection. She immediately went to check the resident's room and found both braces in the closet.
The director said she typically conducted random audits to verify devices were still being used. Her last audit was conducted around two years ago and showed Resident #2 had the devices in place at that time.
"It is the responsibility of the nursing staff to ensure the devices are being applied, and if they are missing, to contact Rehabilitation department for replacement," she told inspectors.
The Director of Nursing insisted the task was documented in the electronic Kardex and nursing assistants were "supposed to be checking the instructions to know what is to be done for their residents."
No physician's order existed for the braces because administrators considered them a nursing intervention that staff needed to implement independently. The devices were meant to prevent the resident from developing further contractures.
"The charge nurses and managers on the unit should be monitoring the Certified Nursing Assistants to ensure they are carrying out all tasks as per the residents' plan of care," the Director of Nursing said.
The Assistant Director of Nursing, who supervised the practical nurses, said staff were educated and expected to be monitored by charge nurses. She wasn't aware devices weren't being applied.
Multiple supervisors described a system where rehabilitation staff recommended devices, nursing staff implemented them, and the interventions were documented in care plans. The Medical Director explained that while some devices required physician orders, knee and elbow braces designed to prevent contractures did not.
"It is usually dependent on the Rehabilitation department who makes the recommendation, nursing staff implements the recommendations and documents it in the resident's plan of care to ensure the interventions are carried out," the Medical Director said.
The breakdown occurred somewhere between the documentation and implementation. Instructions existed in the system. Devices sat ready in the closet. But the nursing assistants responsible for applying them daily couldn't access the information they needed.
The facility's electronic medical record system had changed in a way that made device instructions invisible to the staff members who needed them most. Nursing assistants signed off on completed tasks without seeing what those tasks actually required.
Supervisors who should have been monitoring compliance weren't aware of the problem. The rehabilitation director who prescribed the devices hadn't audited their use in approximately two years.
Meanwhile, Resident #2 went without prescribed medical support designed to prevent joint deterioration. The resident's contractures could have worsened during the unknown period when the braces remained unused.
The inspection revealed a facility where multiple levels of oversight had failed simultaneously. Electronic systems blocked access to critical information. Nursing assistants worked without proper guidance. Supervisors monitored nothing.
When the devices were finally discovered, they were exactly where they should have been stored between uses. They simply had never been taken out again.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brooklyn Ctr For Rehab and Residential Health Care from 2025-11-04 including all violations, facility responses, and corrective action plans.
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