Failure to Apply Prescribed Hand Splint for Resident with Hemiplegia
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the necessary treatment and services to prevent further decline. Resident R65, who has hemiplegia, was observed multiple times without the prescribed resting hand splint on their left hand, despite a sign in the room indicating it should be worn during the day. The resident and their significant other confirmed that the splint was not being applied, and the resident expressed discomfort due to their fingers pushing into their hand. Interviews with the Director of Rehab and the Director of Nursing revealed that the resident was discharged from therapy with a goal to wear the hand splint for eight hours daily. However, the process to incorporate these goals into the resident's care plan was not effectively followed, as evidenced by the repeated observations of the resident without the splint. The Director of Nursing confirmed the oversight, acknowledging that the splint should have been applied daily.
Plan Of Correction
1. Resident #65 had therapy eval completed to ensure that resident required hand splint. Physician and family were updated with recommendations. 2. Current residents with hand splints were reviewed to ensure that orders were current and equipment available and staff were applying the splint. 3. Director of Nursing or designee will educate licensed staff and certified nurse aides on splints/adaptive equipment. Reviewed with staff on where to see orders/tasks for residents with splints/adaptive equipment. 4. Audits of residents with hand splints will be completed to ensure that residents have the splints on as per ordered and proper documentation supporting the wearing of those splints. Audits will be completed 3x weekly for 2 weeks then monthly until compliance is met. Audits will be reviewed at quality assurance meetings monthly until compliance is met.