Failure to Assess and Intervene for Upper Extremity Contracture
Penalty
Summary
A resident with spastic hemiplegic cerebral palsy and scoliosis was observed with a right arm contracture, specifically with the arm pulled to the upper chest and the wrist and hand curling, without any support to prevent involuntary flexion. Despite previous occupational therapy documentation indicating the resident could raise their arms and a prognosis to maintain function with consistent staff follow-through, there was no evidence of current rehabilitative services, physician orders, or care plan interventions to address or prevent the progression of the contracture. The resident's care plan noted limited physical mobility and the need to monitor for complications such as contractures, but the medical record lacked documentation of active interventions or assessments for the right arm contracture. The DON confirmed the absence of care plan interventions and rehabilitative service orders, acknowledging that early detection and intervention for contractures should have been implemented as part of nursing assessments.