Failure to Ensure Proper Use of Back Brace Leads to Worsening Fracture
Summary
The facility failed to provide appropriate treatment and services to maintain or prevent an avoidable reduction in range of motion for a resident with a spinal compression fracture. The resident, who had been diagnosed with an L1 vertebral compression fracture, was not wearing their TLSO back brace correctly, leading to a significant worsening of the fracture. The resident reported that they were not educated on how to properly apply the brace, and facility staff, including therapists and nursing staff, did not provide the necessary assistance or education. Observations and interviews revealed that the resident's back brace was not fitted correctly, and there was no physician order related to the use of the brace documented in the resident's records. The resident's care plans and CNA assignment cards lacked specific instructions for the application and use of the back brace, and the facility did not provide staff with the manufacturer's instructions for the brace until after the deficiency was identified. The resident's family member, who attended a neurosurgery appointment with the resident, confirmed that the brace was not being worn properly and that no education was provided by the hospital or the facility. The Director of Nursing acknowledged that the facility relied too heavily on therapy staff for guidance on the brace and confirmed that there was no documentation of staff training or education regarding the brace. The facility's failure to ensure proper application and use of the back brace resulted in harm to the resident, as the fracture worsened significantly due to the incorrect use of the brace.
Penalty
Resources
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Failure to maintain ROM services for two residents. One resident with ankylosis of the knee, diabetes, and generalized weakness was discharged from PT with a recommendation for a restorative ROM program, but no restorative intervention was added to the care plan and the resident reported not being offered the program. Another resident with diabetes, weakness, and right-sided hemiplegia had an order for a right elbow extension splint, but the restorative program and splinting were discontinued after refusals even though documentation showed the resident was later agreeable when re-approached by staff.
A resident with severe cognitive impairment, bilateral ROM impairments, and hand contractures was supposed to wear bilateral hand splints to help maintain ROM. Staff observed the resident's hands curled into fists while the splint was left on the bedside table, and a CNA admitted she forgot to offer the brace during her shift. An LPN said the resident tolerated the splints and allowed staff to apply them, while the RN Resident Care Manager was unsure why the splints were not worn consistently.
Failure to provide restorative ROM care for a resident with hemiparesis/hemiplegia and a left-hand contracture. The resident’s care plan directed daily PROM to the left upper extremity, but the EMR lacked documentation of PROM, and observations showed the left hand curled into a fist. CNAs and administrative nurses confirmed the resident was not receiving the planned restorative nursing care.
A resident with Huntington's disease, dementia, epilepsy, and contractures to the right elbow and both hands did not receive ordered RNA services for PROM to both arms or application of both hand rolls and the right elbow extension splint during a gap between OT discharge and the start of RNA. Surveyors observed the resident with both arms positioned in flexion/supination and both hands in fists, and the DOR and DON confirmed the lapse in services and that the resident could have potentially experienced a decline in ROM.
Failure to provide and document contracture management for a resident with limited ROM. A resident with stiffness, muscle wasting, unsteadiness, cognitive deficits, and poly osteoarthritis had a left hand contracture and left palm abrasion, but the care plan and orders did not consistently include the foam roll/splint/orthotic equipment or the frequency of use. OT documented decreased hand and wrist ROM, recommended foam tubing progressing to an orthotic device, and set goals for wearing the tubing with minimal redness, swelling, discomfort, or pain.
Failure to provide ordered ROM and splint care. A resident with severe cognitive impairment, aphasia, and dependence for ADLs, mobility, and transfers was observed without the ordered hand splint in place, and the splint was found stored on a drawer. The resident’s ROM and splint orders were not consistently carried out, restorative records showed the plan was not occurring as ordered, and family reported staff were not repositioning the resident or completing ROM, with staff citing short staffing and being pulled to the floor.
Failure to Maintain ROM Services for Two Residents
Penalty
Summary
The facility failed to ensure residents with limited ROM received the necessary services to maintain their level of functioning for 2 of 4 sampled residents reviewed for limited ROM. Resident 24 was admitted with diagnoses including ankylosis of the left knee, diabetes, and generalized muscle weakness. The resident stated they had been told they would start an exercise program after discharge from PT but had not been offered participation in a restorative program. The PT discharge summary recommended a restorative ROM program for both lower extremities, but the care plan initiated on 12/25/2025 did not include any restorative program intervention. The DOR stated the facility failed to initiate and implement a restorative program for Resident 24 after PT discharge. Resident 112 was admitted with diagnoses including diabetes, weakness, and hemiplegia and hemiparesis affecting the right side. Observations showed an elbow splint on a corner table in the resident’s room, and the EHR included an order to apply a right elbow extension splint in the morning for up to six hours per day, as tolerated, three to six times per week. A progress note stated the restorative program and splinting were discontinued per recommendations related to resident refusal, and the care plan, tasks, and restorative aide were updated. The restorative flow sheet showed three refusals of splint assistance between 05/14/2026 and 06/04/2026, with documentation that the resident was re-approached by alternate staff and then agreeable to wear the splint. The restorative aide stated they had no experience with the resident refusing splint assistance, and the DOR stated that three refusals in 30 days was uncommon and did not meet expectations for discontinuing the restorative program.
Failure to Consistently Apply Hand Splints for ROM Support
Penalty
Summary
The facility failed to provide services to prevent further decrease in range of motion for Resident 17, who was admitted with osteomyelitis and whose 2/18/26 Quarterly MDS indicated a BIMS score of 00, severe cognitive impairment, inability to make daily decisions, dependence on staff for daily activities including applying splints, and bilateral upper and lower ROM impairments. The 3/19/26 care plan indicated the resident wore a left-hand carrot splint and a right-hand palm guard to help maintain ROM. During observations on 6/3/26 and 6/4/26, Resident 17's hands were curled into fists and could not be extended, and the resident was not wearing the hand splint, which was observed on top of the bedside table. The resident stated staff allowed the splint to be applied. Staff 8, a CNA, stated the resident's hand contractures were stiff and difficult to manage and admitted she did not offer to apply the brace during her shift because she forgot. Staff 9, an LPN, stated the resident used bilateral hand splints to prevent further decrease in ROM, tolerated them, and allowed staff to apply them, but staff did not tell her they were unable to apply the splint during the day. Staff 10, the RN Resident Care Manager, stated he was unsure why the resident did not wear the hand splint consistently and acknowledged the splints should be worn.
Failure to Provide Restorative ROM Care for Resident with Left-Hand Contracture
Penalty
Summary
The facility failed to provide restorative care to a resident with hemiparesis/hemiplegia and limited range of motion, including a contracture of the left hand. The resident’s EMR documented a diagnosis of hemiparesis/hemiplegia, and MDS assessments showed moderately impaired cognition with limited ROM on one side of the upper and lower extremities. The care plan revised 04/14/2026 directed staff to provide passive ROM restorative care to the resident’s left upper extremity daily, including opening and closing the left hand, elbow extension, and shoulder raises for 15 minutes up to seven days per week. The resident’s EMR from 05/04/2026 through 06/01/2026 lacked documentation that PROM was provided. During observation on 06/01/2026, the resident was feeding herself with her right hand while her left hand rested in her lap with fingers curled inward into a fist. On 06/03/2026, CNAs transferred the resident with a full body lift and the left hand remained curled into a fist. CNA O stated she would open the resident’s left hand enough to clean her fingers and palm but the resident was not able to fully open the hand and move her fingers. CNA O was unsure whether restorative care was being provided, CNA M stated the resident did not receive restorative care, and Administrative Nurses E and D confirmed the resident had not been receiving the planned restorative nursing cares for the left-hand contracture.
Failure to Provide Ordered ROM Services and Splinting
Penalty
Summary
The facility failed to provide ROM services for a resident with Huntington's disease, epilepsy, dementia, and contractures to the right elbow and both hands. The resident's MDS showed severe cognitive impairment, no speech, dependence for hygiene and dressing, and functional ROM limitations in both arms and legs. OT discharge documentation indicated the RNA was to provide exercises to the neck and both arms and to apply the right elbow extension splint and both hand splints, and physician orders later directed PROM to both arms five times per week as tolerated and application of both hand rolls and the right elbow extension splint for four to six hours as tolerated, five times per week. Surveyors observed the resident lying in bed with the right arm in forearm supination and the right hand in a fist, and later with both elbows bent, both forearms in supination, and both hands in fists. The DOR stated the RNA program should have started when OT recommended it, but the resident did not receive RNA services between OT discharge and the start of RNA on 1/2/2026. The DOR and DON both stated there was a gap in services and that the resident could have potentially experienced a decline in ROM without receiving PROM and the splints/hand rolls. The facility policy stated residents with limited ROM will receive treatment and services to increase and/or prevent further decrease in ROM.
Failure to Provide and Document Contracture Management for Left Hand ROM
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received the treatment and services needed to increase range of motion and that the care plan included specific, person-centered interventions for left hand contracture. Resident #4 was an older male with diagnoses including stiffness of unspecified joint, muscle wasting and atrophy of the upper arm, unsteadiness on feet, cognitive communication deficit, unspecified intellectual disabilities, and poly osteoarthritis. The record showed a care plan for skin integrity problems related to an abrasion to the left palm, pain related to arthritis and left hand contracture, and physical mobility related to weakness and a contracted left hand, with interventions including a foam roll to the left hand, abductor wedge, halo bars, and monitoring for worsening contracture and skin breakdown. Record review showed the active order summary did not include an orthotic device or foam roller/abduction wedge for mobility intervention, and the task list did not indicate the frequency of foam roller use or splint use. Occupational therapy documentation stated the resident received therapy for contracture management and had decreased hand and wrist ROM, with recommendations to begin with foam tubing in the left palm and progress to larger tubing and eventually an orthotic carrot. OT goals included wearing orthotic foam tubing in the left palm for up to 2 hours, then up to 8 hours with minimal redness, swelling, discomfort, or pain. The OT progress report also noted the facility did not have a restorative program and nursing staff would continue promoting participation in ADL tasks such as contracture management after OT discharge.
Failure to Provide Ordered ROM and Splint Care
Penalty
Summary
The facility failed to ensure that Restorative Therapy for range of motion (ROM) and splint application were provided as ordered for one resident with severe cognitive impairment and dependence for activities of daily living, mobility, and transfers. The resident had diagnoses including traumatic hemorrhage of the right cerebrum, disorder of the autonomic nervous system, neurocognitive disorder, and aphasia. The resident was observed lying in bed with arms and hands resting on top of the blankets and hands closed in fists, and a hand splint was observed placed on top of a drawer under the television rather than on the resident. The resident was later observed in a reclining wheelchair in the common area without the hand splint on. The resident’s restorative orders included active ROM to both upper and lower extremities 5 to 7 days per week and splint use to the right upper extremity for 2 hours on and 2 hours off, 5 to 7 times per week. The restorative documentation showed inconsistent completion, including entries indicating ROM and splint goals were not meeting the goal and that the plan was not occurring as ordered. The monthly restorative records also reflected limited participation counts for ROM and splint/brace programs. Interviews with the resident’s confidential visitors reported that staff were not repositioning the resident every two hours, were not completing ROM exercises, and were not consistently applying the hand splint. The visitors stated that staff often said they were short staffed and pulled to the floor. A CNA assigned to the resident reported being pulled to floor assignments and stated that when pulled, restorative therapy tasks could not always be completed. The MDS nurse reported that restorative tasks were entered for daily completion, that CNAs assigned to the resident were responsible if the restorative aide could not do the plan, and that she was unsure why the ROM and splint application were not being completed. The therapy director stated the ROM and splint plan was intended to maintain ROM and positioning, and the administrator and corporate nurse reviewed that the documented look-back showed ROM and splint application were not completed as ordered.
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