Failure to Apply Prescribed Hand Roll for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decline. Specifically, Resident #41, who had moderately impaired cognition and was dependent in all areas of activities of daily living, was observed multiple times without a left-hand roll in place as per physician's orders. The resident had a care plan focused on restorative nursing rehabilitation, which included the use of a left-hand roll to be worn at all times except for skin checks and hygiene. Despite these orders, the resident was observed without the hand roll on several occasions during the survey period. Interviews with facility staff revealed a lack of adherence to the prescribed care plan. Certified Nursing Assistant #8, who was responsible for the resident's care, admitted to not applying the left-hand roll and was unaware of its location. Registered Nurse #1 confirmed the resident's dependency on staff for activities of daily living and the necessity of the hand roll to prevent stiffness. The Director for Rehabilitation also noted the absence of the hand roll and stated that CNAs were responsible for its application. The Director of Nursing acknowledged the risk of contractures if the hand roll was not applied, emphasizing the responsibility of CNAs to apply the device and the oversight role of RNs and LPNs.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 Element #1 Resident #41 was immediately given a new hand roll. The CNA whom had resident #41 was disciplined for not providing the resident’s hand roll. Element #2 The Director of Rehabilitation reviewed all residents with assistive devices to ensure assistive devices are present and in use. Element #3 The nursing staff will be educated to use assistive devices that are ordered by the physician. The policy was reviewed and no revisions were made. Element #4 An audit tool will be developed by the Director of Rehabilitation to monitor the use of assistive devices. Audits will be done weekly for three months and then quarterly. All findings and corrective actions if indicated will be discussed with the administrator. The Director of Rehabilitation will present findings and corrective actions if indicated to the QAPI committee and thereafter the QAPI committee will determine the frequency of reports. Element #5 Director of Rehabilitation 5/01/2025