Failure to Provide Proper Positioning and ROM Support for Residents with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion (ROM) and prevent further decline in two residents with limited mobility and contracture risk. One resident, who had a history of stroke with right-sided paralysis and cognitive impairment, was observed multiple times lying on their affected right side with their paralyzed arm and hand positioned underneath their body without support. The resident complained of pain, and their right arm and hand appeared red and swollen. Although a soft hand brace had been prescribed, it was removed due to a laceration, and no alternative support or positioning device was provided. The care plan and bedside care documentation did not include interventions for right arm or hand positioning, and staff were unaware of the lack of proper positioning. Another resident with muscle weakness, lymphedema, right shoulder pain, osteoporosis, and severe cognitive impairment was observed sitting in a wheelchair with their right arm and hand unsupported, red, and swollen. The resident's arm positioning device had been broken and removed months prior, and staff used a teddy bear or were supposed to use a pillow for support, but these interventions were inconsistently applied. The care assignment documentation for nursing assistants did not include instructions for right arm or hand positioning, and staff acknowledged that no interventions were in place for this need. In both cases, the lack of consistent use of assistive devices and absence of clear care plan interventions for positioning and support led to residents being left without necessary measures to prevent further decline in ROM and contracture. Staff interviews confirmed gaps in awareness and implementation of required positioning supports, and documentation failed to reflect the residents' needs for proper positioning and use of assistive devices.