Failure to Provide Contracture Care and Ensure Splint Use
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care for contractures in a resident with a history of spastic hemiplegia, contractures, and brain injury. The resident, who is moderately cognitively impaired and dependent on staff for mobility, was observed with contractures in both upper extremities and no splints in place. The resident reported that staff had not applied his hand splints for some time and did not ask if he wanted to wear them. One splint was found across the room, not in use. The care plan indicated the resident should wear a right hand splint for up to four hours at night, but there was no documentation in the electronic medical record task list for staff to chart the application of splints. Interviews with therapy staff revealed uncertainty about whether the resident was wearing the splint as scheduled or if it still fit. Occupational therapy documentation from previous periods indicated a splint wear schedule was in place, but current staff were unsure of its implementation. The lack of documentation and inconsistent application of the splint as per the care plan led to the deficiency in providing appropriate treatment and services to prevent further decrease in range of motion for the resident.
Plan Of Correction
F688 1. Resident #3 still currently resides in the facility; His care plan was reviewed, and orders were entered in order for staff can document the application and removal of his splint. 2. Like residents are identified as those with limited contractures. The plans of care for all like residents were reviewed by 4/25/2025 and updated to reflect the residents' current needs and treatment. Therapy referrals have been made if indicated, and documentation verification entered for any residents using a positioning device. 3. Policies for ROM and applying splints have been reviewed and revised. Nursing staff and therapy staff were educated by the DON/designee by 4/25/2025 on appropriate process related to this policy. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of residents currently in the facility receiving care for contractures. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.