Failure to Ensure Prescribed Arm Tray Was in Place for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with a history of Alzheimer's disease, stroke, right side hemiplegia, and limited range of motion was observed multiple times sitting in a wheelchair without the prescribed right shoulder arm tray in place. Instead, the resident's right arm was elevated on a small bed pillow. The care plan and physician's order both specified that the resident was to use a right shoulder arm tray to support the right upper extremity while upright in the wheelchair for joint protection and proximal support. Documentation in the Medication Administration Records indicated that the tray was signed out as being on the wheelchair every day shift, with no documented refusals. Interviews with staff revealed that the arm tray was stored between the dresser and nightstand and was supposed to be attached to the wheelchair whenever the resident was up. Staff also noted that the resident's daughter might sometimes request its removal, but there was no documentation of such refusals. The Director of Nursing confirmed that the tray was to be on the resident's wheelchair, indicating a failure to ensure the assistive device was consistently in place as ordered and care planned.