Failure to Provide Appropriate ROM Services
Penalty
Summary
The facility failed to ensure that two residents with limited range of motion received appropriate services to prevent further decline in their condition. Resident R26 had physician orders for a hand grip splint and elbow positioning wedges to be alternated every four hours. However, observations revealed that the resident was not wearing any devices or splints during the survey, and the splints were found on the windowsill instead. An LPN confirmed that the resident should have been wearing the splints as per the physician's orders. Similarly, Resident R33 had physician orders for an abductor wedge to be positioned between the legs at all times as tolerated and bilateral upper extremity splints to be applied for four hours and removed for four hours. Observations showed that the resident was not wearing any devices or splints, and no such equipment was found in the resident's room. An LPN was unsure if the resident should be wearing any devices and could not locate them in the room. These findings indicate a failure to provide necessary care and services to maintain or improve the residents' range of motion and mobility.
Plan Of Correction
1. Residents R26 & R33 had splints obtained and applied per physician orders. 2. Other Residents with splints & devices were checked for proper appliance per physician orders. 3. Restorative C.N.A. and nurses were in-serviced on Policy for splints & devices. 4. Random Audits will be conducted by ADON or designee weekly to ensure proper application of splints/devices per orders. Results of audits will be brought to monthly QAPI meeting x3 months, overseen by the Administrator, by 3/31/25.