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
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A resident with a history of stroke, contractures, and vascular dementia had physician orders and a care plan requiring a left-hand palm protector or hand roll splint to be applied daily and nightly with skin checks and hand hygiene. The Treatment Administration Record indicated these interventions were consistently completed, but repeated observations over several days showed the resident without any palm protector or splint in the affected hand while in bed, in a wheelchair, and during activities. An RN confirmed the device was not in place and had been missing from the room for several days, resulting in a failure to provide ordered ROM support for the resident’s contracture.
A resident with quadriplegia and hand contractures did not receive prescribed rolled washcloths or splints to both hands as ordered, and staff confirmed the absence of a restorative program to maintain or improve range of motion after therapy services ended. Observations and staff interviews verified that the resident's contracture interventions were not in place, and no system existed to prevent further decline in functional abilities.
Several residents with complex medical conditions did not consistently receive restorative nursing services as outlined in their care plans, including ambulation, ROM exercises, and ADL support. Documentation frequently showed missed or unperformed interventions, and staff interviews confirmed a lack of knowledge and inconsistent implementation, affecting the residents' functional maintenance.
A resident with bilateral hand contractures and multiple psychiatric diagnoses did not receive a recommended splint and brace program after discharge from OT. Despite OT recommendations for bilateral hand splints and ROM exercises, there were no physician orders or restorative program in place, and staff confirmed that no such interventions were implemented.
Two residents with contractures did not receive their physician-ordered splint devices as required. Despite clear orders and care plan interventions for the use of a palm protector and a c-roll splint, observations over several days showed that neither device was applied. Staff interviews revealed confusion about responsibility for applying the devices, and facility policy regarding splint use was not followed.
Four residents with conditions such as cancer, chronic kidney disease, dementia, and hemiplegia did not receive restorative nursing services (RNS) for ambulation, range of motion, and strengthening as ordered and care planned. Facility records and resident interviews confirmed that therapy sessions were missed or inconsistently provided, and staff acknowledged the lack of documentation and delivery of these services.
Failure to Implement Ordered Palm Protector for Contracture Management
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered range of motion support for a resident with a left-hand contracture. The resident was admitted with multiple diagnoses including stroke, contractures, vascular dementia, hypertension, depression, and anxiety, and required staff assistance with ADLs while having intact cognition. Physician orders directed that a left-hand palm protector be applied each morning and removed at bedtime with skin integrity checks each shift, and that the resident tolerate a hand roll splint or palm protector nightly, with the left hand thoroughly washed and dried before and after use. The resident’s ADL functional status care plan also specified use of a palm protector to the left hand for contracture management. The Treatment Administration Record for the review period showed these orders as completed as written. However, multiple observations over several days showed the resident without a palm protector or hand roll splint in the left hand while in bed, in a wheelchair, and participating in activities. On each observed occasion, no palm protector was visible despite the active orders and documented completion on the TAR. In an interview, an RN confirmed that the resident did not have a palm protector in place and reported that the device could not be found in the room and had been missing for several days. This discrepancy between physician orders, care plan, documented implementation, and actual practice led to the cited deficiency for failure to maintain range of motion for a resident with contracture.
Failure to Maintain Restorative Program and Hand Contracture Interventions
Penalty
Summary
The facility failed to implement a restorative program to prevent the decline of residents' functional abilities, specifically for a resident with contractures of both hands. The resident had multiple diagnoses, including quadriplegia and contractures, and physician orders directed that rolled washcloths be applied to both hands twice daily. The care plan also included this intervention. However, observations revealed that the resident's hands were clenched in a tight-fisted position without the prescribed splints or washcloths in place. This absence was verified by nursing staff during the survey. Interviews with facility staff, including LPNs and the Therapy Director, confirmed that there was no restorative program in place to address range of motion exercises or to implement therapy recommendations after therapy services were discontinued. The Therapy Director acknowledged that residents who had received therapy services were at risk for functional decline due to the lack of restorative follow-up. The Assistant Director of Nursing also verified the absence of a restorative program and the failure to maintain the resident's hand splints as ordered.
Failure to Provide and Document Restorative Nursing Services per Care Plans
Penalty
Summary
The facility failed to provide restorative nursing services as outlined in the care plans for four residents who were at risk for decline in range of motion (ROM), mobility, and activities of daily living (ADL) performance. Each resident had individualized care plans and therapy discharge recommendations specifying daily restorative interventions such as ambulation with assistive devices, active and passive ROM exercises, and support with ADLs. Despite these documented interventions, point of care documentation revealed frequent omissions, with services marked as not applicable (N/A) or left blank on multiple days and shifts for all four residents. Interviews with staff, including CNAs and facility leadership, confirmed that restorative services were inconsistently provided. One CNA reported not performing restorative services due to a lack of knowledge and stated that there was no designated restorative aide. The Corporate Mobile DON and Regional Director of Clinical Services acknowledged ongoing inconsistencies in the provision and documentation of restorative care, attributing some of the lapses to agency staff, who were nonetheless expected to follow the care plans. Residents also reported that restorative exercises were not being performed as intended. The affected residents had significant medical histories, including Parkinson's disease, major depressive disorder, chronic obstructive pulmonary disease, muscle wasting, Alzheimer's disease, and dementia. Their care plans were designed to maintain or improve their functional abilities and prevent further decline. However, the facility's failure to consistently implement and document restorative nursing interventions as required by the care plans resulted in a deficiency affecting multiple residents.
Failure to Implement Splint/Brace Program for Resident with Hand Contractures
Penalty
Summary
The facility failed to implement a splint and brace program for a resident with bilateral hand contractures, as identified through medical record review, observation, staff interviews, and facility policy review. The resident had a history of bipolar disorder, anxiety, depression, suicidal behavior, and contractures, and was dependent on staff for care, bathing, and transfers. Occupational therapy (OT) had previously recommended the use of bilateral hand splints, passive range of motion (PROM) exercises for the left hand, active range of motion (AROM) exercises for the right hand, and verbal cues for self-feeding. However, there were no physician orders in place for the use of splints or for a restorative program involving PROM and AROM exercises. Observation revealed that the resident was not using splints, and interviews with the Therapy Director and Assistant Director of Nursing confirmed that no restorative program had been implemented following OT discharge. The OT had not written orders or completed an evaluation for the implementation of a splint and ROM restorative program, and the nursing restorative staff did not have a program to follow. Facility policy indicated that properly used splints and braces can enhance mobility and protect extremities, but this was not carried out for the resident in question.
Failure to Provide Physician-Ordered Splint Devices for Residents with Contractures
Penalty
Summary
The facility failed to provide physician-ordered splint devices to residents with contractures, as evidenced by the care of two residents reviewed for range of motion. One resident, with diagnoses including paralytic syndrome, polyneuropathy, and contracture of the right hand and wrist, had a physician order and care plan intervention for a right palm protector to be applied daily for up to eight hours. Despite this, multiple observations over several days showed the resident was not wearing the palm protector. Interviews with nursing staff and CNAs revealed confusion and lack of clarity regarding responsibility for applying the device, with none of the interviewed staff having applied the palm protector as ordered. Another resident, diagnosed with contracture of the left hand and elbow as well as hemiplegia and hemiparalysis, had an active physician order and care plan for a left c-roll splint to be applied for six hours daily. Observations on multiple occasions found the resident in bed with contracted extremities and no splint or device in place. Staff interviews confirmed the resident had not had the splint applied during the observed period. Facility policy indicated that splints and braces are to be used to enhance mobility and maintain alignment, but these were not provided as ordered for the residents in question.
Failure to Provide Restorative Nursing Services as Ordered and Care Planned
Penalty
Summary
The facility failed to provide restorative nursing services (RNS) as ordered and care planned for four residents who required therapy to maintain or improve range of motion, mobility, and strength. For one resident with diagnoses including malignant neoplasm of the prostate, chronic kidney disease, dementia, and a history of falls, the care plan and physician orders specified RNS for ambulation up to six times a week. However, there was no evidence in the medical record that these services were completed. Staff interviews revealed that restorative therapy was not consistently provided, with one CNA stating she was unable to complete therapy when assigned to other duties, and the Director of Clinical Services indicating the resident was not on a restorative program at the time. Another resident with malignant neoplasm of the stomach and diabetes required maximum assistance for ambulation and was care planned to receive RNS for ambulation and strengthening exercises with ankle weights. Facility records showed that this resident did not receive therapy for ambulation or strengthening in one month, received minimal therapy the following month, and did not receive strengthening therapy in the subsequent month. Both the resident and a family member confirmed that therapy, including the use of weights, had not been provided for weeks. Two additional residents with hemiplegia and hemiparesis following cerebral infarction were also affected. Their care plans included RNS for range of motion, strengthening, and transfer exercises with ankle weights, to be provided six to seven times a week. Facility flow records indicated significant gaps in the provision of these services, with some months showing only one or a few sessions and other months with no therapy documented. Interviews with these residents confirmed that restorative therapy was not being provided as planned. Facility administrators acknowledged the lack of evidence to show that restorative therapy was delivered according to the care plans.
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