Failure to Implement Physician-Ordered Splint for Resident
Penalty
Summary
The facility failed to ensure the proper implementation of a physician-ordered positioning device for a resident with range of motion impairment in the bilateral upper extremities. The resident had an active physician's order for a splint to be applied to the right hand at specific times throughout the day. However, observations and staff interviews revealed that the splint was not consistently applied as ordered. The resident was observed without the splint on multiple occasions, and staff confirmed that the splint was not applied after lunch as required. Further investigation showed that the splint was in poor condition, with worn-out Velcro and missing foam spacers due to the resident chewing on it. Despite recommendations from occupational therapy to use a tubi-grip sock over the splint to prevent chewing and extend its longevity, this was not implemented. The staff documented the application of the splint even when it was not in use, indicating a failure to adhere to the care plan and physician's orders. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 12's new right-hand splint arrived before the exit conference. Staff on duty at the time were verbally re-educated on the splint schedule (which specifies when to apply and remove the hand splint) for this resident. Resident was wearing splint as directed without difficulty. The plan of care was reviewed and updated as indicated. 2. All residents with hand splints were reviewed to ensure the splint was present and in good repair. Staff also reviewed the current hand splint schedule (which specifies when to apply and remove the hand splint). The plan of care was reviewed and updated as indicated. 3. The Director of Nursing and/or designee will educate the RNs, LPNs, and CNAs on the need to ensure splints are present and in good repair and where to note the current hand splint schedule. 4. DON or designee will audit residents with hand splints to ensure splints are on as per the plan of care and in good repair weekly x4 then monthly x2 or until substantial compliance is achieved. Results will be reviewed at the QAPI meeting.