Failure to Apply Splints and Orthotics as Ordered for Residents with Limited Mobility
Penalty
Summary
The facility failed to follow physician orders and care plans regarding the application of splints, braces, or soft foam devices for three residents with hemiplegia or contractures. One resident with hemiplegia affecting the left side had a physician order and care plan requiring a splint to the left upper extremity for 4-6 hours daily, but the resident reported not knowing about the splint and was observed without it on multiple occasions. Staff confirmed the splint was not applied because the resident was in bed and only restorative staff applied splints, which did not occur on the observed days. Another resident with hemiplegia and aphasia had a physician order and care plan for a left foot orthotic to be worn daily when out of bed, but the resident reported not having the orthotic for months due to improper fit. Staff were unaware of the issue until the survey, and the resident was observed without the device, with the foot turned inward. A third resident with hemiplegia had a physician order and care plan for a soft foam/sponge to be applied to the left hand, but was observed without it, and staff confirmed it was not applied due to time constraints. The facility's restorative policy requires individualized restorative care to maintain or improve residents' range of motion, but these interventions were not consistently implemented.