Failure to Document and Monitor Hand Brace for Resident
Penalty
Summary
The facility failed to ensure proper documentation, assessment, and monitoring of a hand brace/splint for a resident who was reviewed for rehab and restorative services. The resident, who was observed with a splint/brace on her right hand, reported that her daughter had provided the brace and staff assisted her in putting it on and off. However, the resident did not perform any exercises for her right hand or arm. The resident's medical records, including the Face sheet, Minimum Data Set (MDS) assessment, and physician orders, indicated that she had multiple diagnoses, including paraplegia, heart failure, COPD, diabetes, and others. Despite an order allowing the use of a soft brace, there was no documentation of restorative services or assistance with the brace in the electronic medical record (EMR), Medication Administration Record (MAR), Treatment Administration Record (TAR), or care plans. Interviews with facility staff, including the Therapy Director and Clinical Care Coordinator, revealed that the facility did not have a dedicated restorative nursing department, but nurse aides were trained to perform restorative functions. The Clinical Care Coordinator acknowledged the existence of an order for the brace but confirmed the absence of further documentation or a care plan related to the brace. The facility's policy on the Restorative Nursing Program emphasized evaluating residents individually to maintain their highest functional level, yet there was no evidence of such evaluation or documentation for the resident's hand brace. This lack of documentation and monitoring represents a deficiency in the facility's care for the resident.