Failure to Implement Hand Splint Intervention for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with dementia and right-sided weakness and paralysis following a stroke was not provided with appropriate interventions to maintain or improve range of motion (ROM) as outlined in her care plan. The care plan specified that the resident should wear a right hand resting splint from morning to bedtime. However, multiple observations over several days revealed that the resident consistently did not have the splint on her right hand, despite the splint being present on the bedside table. Staff were observed providing care without offering or applying the splint, and the resident reported that staff had not asked her if she wanted the splint on during those times. The lack of adherence to the care plan was confirmed through both staff actions and resident interviews. The resident was observed in bed and in a wheelchair, participating in activities such as bingo, without the splint in place. At no point during the observed care interactions did staff attempt to apply the splint or inquire about its use, despite the resident's care plan directive. This failure to implement the prescribed intervention resulted in the facility not providing appropriate care to maintain or improve the resident's ROM.
Plan Of Correction
F tag 688 Increase/Prevent/Decrease in ROM/Mobility SS=D 1. Resident #25 was evaluated to determine if the resident had any new discomfort or worsening of contracture due to the staff's failure to offer and utilize her right-hand splint. The care plan was reviewed and updated as needed. 2. Residents residing in the facility with splints or other contractual devices have the potential to be affected by the deficient practice. The nursing team reviewed patients with contractual devices to ensure devices were being offered and utilized by physician order. Any refusals were documented, and care plans were updated to reflect preferences. 3. The QAPI Committee reviewed the Brace and Splint Program and deemed it appropriate. Nursing staff were re-educated by the DON/Designee on the Brace and Splint Program. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. 4. The DON/Designee will review 5 residents weekly for four weeks to ensure that their devices are being utilized by physician order, then monthly for 3 months. The results of these audits will be forwarded to the QAPI Committee for further guidance and direction. The NHA is responsible for continued compliance.