Failure to Provide Physician-Ordered Splint for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the physician-ordered treatment and services necessary to prevent further decrease in range of motion. Resident R27, who was admitted with conditions including flaccid hemiplegia affecting the left non-dominant side, diabetes, and hypertension, had a physician's order for a left resting hand splint to be worn during waking hours. The order also required frequent skin checks for signs of irritation or breakdown and allowed removal of the splint for hygiene purposes. Observations over several days revealed that Resident R27 was not wearing the left resting hand splint as ordered. On multiple occasions, the splint was observed lying on the resident's bedside table while the resident was either in bed or sitting in a wheelchair in the lounge. During an interview, the Director of Nursing confirmed that the resident did not have the splint on as per the physician's orders, acknowledging the failure to comply with the prescribed treatment plan.
Plan Of Correction
R27 no longer needed the left-hand splint; therefore, the order has been discontinued. The facility has ensured that all current residents with physician-ordered treatments and services to prevent further decrease in range of motion are utilized as ordered. An initial audit was conducted by the Director of Nursing after the concern was brought to the facility's attention. The Director of Nursing and/or designee will educate the nursing staff on the importance of providing residents with a limited range of motion, the appropriate treatment and services to increase range of motion, and/or to prevent further decrease in range of motion. A nursing designee will conduct audits on 5 random residents 3 times a week for four weeks to ensure residents with physician-ordered treatments and services to prevent further decrease in range of motion are utilized as ordered. The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.