Failure to Ensure Proper Use of Palm Guards and Range of Motion Exercises
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decline. Specifically, the staff did not ensure that the resident's left and right palm guards were worn as recommended by occupational therapy. Observations revealed that the resident's hands were not equipped with palm guards during multiple checks, and there was inconsistent documentation of range of motion exercises being performed as per the care plan. The resident in question had a history of cerebral vascular accident, dysphasia, and muscle weakness, with severe cognitive impairment. The care plan required the resident to be on a restorative nursing program, which included assistive active range of motion exercises for the lower extremities and passive range of motion for the upper extremities. The resident was also supposed to wear palm guards except during specific activities. However, the palm guards were not consistently applied, and there were gaps in the documentation of range of motion exercises. Interviews with staff revealed a lack of communication and adherence to the care plan. Certified Nursing Assistants and Licensed Practical Nurses were responsible for ensuring the resident wore the palm guards and received range of motion exercises, but there was no process in place to monitor the documentation. The Director of Nursing and other staff acknowledged the importance of following the care plan but failed to ensure its implementation, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved December 30, 2024 1. Resident #30 was reviewed by PT/OT for range of motion. Resident #30 had left and right palm guards applied per plan of care. All staff on resident #30 was trained on residents plan of care for left and right palm guards. All staff on resident #30's unit was trained on documentation for range of motion and residents plan of care by RN Educator. 2. All residents with Range of motion orders are at risk for deficient practice of not providing Range of motion or adaptive equipment per plan of care. 3. Director of Nursing reviewed policy and procedure on Range of motion and splints. No changes were made to policy. 4. All Residents with Range of motion orders and/or splints were audited to ensure resident had adaptive equipment applied per plan of care by RN. All residents documentation for past 30 days was audited by RN for documentation regarding ROM and splint use. Any deficient practices were immediately corrected and brought to QAPI for further review. 5. All nursing staff were trained on policy and procedure of ROM and policy and procedure for splint care by RN Educator. 6. 5 residents on Range of Motion will be audited by MDS weekly for 2 months and monthly for 3 months for documentation on range of motion. Any deficient practices will be immediately corrected and brought to QAPI for further review. 5 residents with splint application will be audited by therapy to ensure splints are applied per plan of care, this will be done weekly for 2 months and monthly for 3 months. Any Deficient practices will be corrected immediately. Person Responsible: Therapy Director