Failure to Implement Contracture Prevention Measures
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, hemiparesis, dysphagia, and a sacral pressure injury was observed multiple times with a contracted left hand bent up on his chest, without any device in place to address the contracture. The resident's record and a facility-obtained picture indicated that a rolled washcloth should be used in the contracted hand to prevent further injury. However, during several observations, no such device was present. The DON confirmed that the rolled washcloth was intended to be in place as an intervention for the contracture. The facility's Restorative Nursing Program policy requires appropriate nursing and restorative services, including contracture prevention and management, but these were not consistently implemented for this resident.