Failure to Provide Necessary Assistive Devices
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent further decrease in range of motion for five residents. Resident R15, who was admitted with a history of stroke, anemia, and atrial fibrillation, was observed multiple times without the prescribed palm guard for his left hand contracture. Despite physician orders and care plans indicating the need for the palm guard, it was not applied, as confirmed by an LPN. Resident R22, diagnosed with non-Alzheimer's dementia, bipolar disorder, and high blood pressure, was observed without the required bilateral wedges, heel lift boots, and knee extension splint. The equipment was found on top of the wardrobe closet, and a nurse aide confirmed that the resident had not used the devices for several days due to staffing issues. Similarly, Resident R43, with schizophrenia and seizure disorder, was observed with a left-hand contracture without a splint, which was not ordered as required. Resident R45, with cerebral palsy and quadriplegia, was not wearing the prescribed splints for his elbows and hands during observations. A nurse aide confirmed the absence of these devices. Lastly, Resident R50, with an acquired absence of the right leg and muscle weakness, was not provided with the left knee extension splint as ordered. The resident reported minimal use of the splint since admission, and staff were unaware of its location. The Vice President of Clinical confirmed the facility's failure to provide the necessary treatment and services for these residents.
Plan Of Correction
Resident # 50 no longer resides at the facility. Resident #s 15, 22, 43, 45 were assessed by the DON/Designee with no negative findings. Resident #15's left palm guard was placed on the resident. Heel lift boots were applied and bilateral wedges and left knee extension splint placed on resident # 22 per physician orders. Resident #43 was assessed by therapy for the need of a splint on 1/9/25. Bilateral hand splints and bilateral elbow splints were placed on resident # 45. All residents with orders for splints, wedges, and heel lift boots have the potential to be affected. The DON/Designee will audit all residents with orders for splints, wedges, and heel lift boots to ensure they are applied as ordered. Findings will be corrected at the time of the initial audit. The DON/Designee will educate licensed nurses and CNAs on applying as ordered. The DON/Designee will audit all residents with orders for splints, wedges, and heel lift boots weekly x 4 weeks to ensure they are applied as ordered. Audits and education will be submitted to the QAPI Committee for review and approval.