Deficiencies in Positioning and Mobility Care
Penalty
Summary
The facility failed to provide appropriate treatment and care in accordance with professional standards for three residents concerning positioning and mobility. Resident #16, who had a left-hand contracture, was not provided with a positioning device to manage their condition. Observations revealed that the resident's left hand was contracted into a fist with long fingernails curling inside, and there was no care plan or physician's orders addressing the contracture. The Registered Nurse Unit Manager acknowledged the oversight and stated that a rehabilitation screen request should have been sent earlier. Resident #60, who required a tilt-in-space wheelchair, was not positioned correctly, leading to unsafe postures such as leaning to the left and having their head unsupported. Observations showed the resident in various positions without proper support, and there was no documented guidance for staff on how to use the specialized wheelchair. Interviews with staff revealed a lack of awareness and education regarding the correct use of the wheelchair, and the Director of Rehabilitation admitted that the necessary instructions were not included in the care plan or provided to the staff. Resident #37, who was at risk for pressure ulcers, was not consistently provided with heel boots as ordered by the physician. Observations noted the absence of heel boots during multiple instances, and the Treatment Administration Record showed missing signatures for the application of the boots on several days. Staff interviews confirmed that the resident did not use heel boots, and there was no documentation of refusal by the resident. The Registered Nurse Unit Manager confirmed that the heel boots should have been in use and documented accordingly.