Failure to Apply Prescribed Palm Guard for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion and mobility received the necessary care and equipment to maintain or improve function. Specifically, a resident with severely impaired cognition and an upper extremity impairment was observed on three separate occasions without the prescribed left palm guard, which was ordered by the physician to prevent further contractures. The facility's policy required the nursing department to apply and remove such devices daily, and the nurse manager was responsible for ensuring this information was recorded in the Certified Nurse Aide Accountability Record. During interviews, a Certified Nurse Aide admitted to not applying the resident's palm guard despite knowing it was their responsibility. The Registered Nurse Manager was unaware that the resident was not wearing the palm guard, and the Director of Rehabilitation confirmed the importance of the device in preventing contracture worsening and protecting the resident's hand. The deficiency was identified during a recertification survey, highlighting a lapse in adherence to the facility's policy and physician's orders.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified ò Upon notification of this deficiency, resident #40 was reassessed and noted to have no new injuries nor ill effects as a result of this deficient practice. ò Resident 40 left palm guard was immediately placed. ò Palm guard placed in treatment orders to be signed off by nurse. ò Nurse manager #10 and CAN #8 were both provided education on ensuring that resident devices were placed daily as per order. Residents at Risk ò The Director of Nursing conducted an audit to identify any other resident that may have been affected by this deficiency, and no other resident was identified. ò While all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Changes ò The facility reviewed Policy and Procedure titled Issues of Splints, Orthoses, and Prostheses and no revision is needed. ò All nursing staff will be educated on policy listed above and the importance of placing adaptive equipment per physician order. ò An audit tool was created by the DON to ensure compliance with adaptive equipment for individuals with limited position and mobility. Monitoring of Corrective Actions ò The Director of Nursing or Designee will randomly observe 3-5 residents who have limited position and mobility to ensure their equipment are being used and physician orders [REDACTED]. Any issues noted will be addressed immediately and reported to the administrator. ò On a monthly basis, the Director of Nursing will report the findings to the Administrator. ò On a monthly basis, the Director of Nursing or Designee will report findings to the QAPI Committee. ò QAPI Committee to determine if further action is required. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025