Failure to Apply and Document Splint Use for Resident with Contracture
Penalty
Summary
A deficiency occurred when a resident with a right-hand contracture did not receive appropriate treatment and services to maintain or improve range of motion as ordered. The resident, who had a history of cerebral infarction, right upper arm muscle wasting, and right-hand contracture, was care planned to use a right palm guard splint to minimize contracture. Physician orders required the splint to be applied daily and removed at bedtime, with cleaning of the hand. However, multiple observations over several days showed the resident without the splint in place, and there were no interventions observed for the right hand. Record reviews revealed no documentation of the resident refusing the splint, despite staff interviews indicating that the resident sometimes refused the splint due to tenderness. The care plan did not indicate any refusals, and the treatment administration record showed the splint was being documented as applied, even when it was not. Nursing staff acknowledged that refusals should be documented in the progress notes and care plan, and that the splint should not be signed off as applied unless it was actually in place. The nurse responsible admitted to marking the medication administration record as completed before verifying the splint was applied. Interviews with the DON and Administrator confirmed that the nurse was responsible for ensuring the splint was applied as ordered, documenting refusals, and notifying leadership if there were issues. The facility's policy required residents with limited range of motion to receive treatment and services to prevent further decline, and for care plans to include specific interventions. The lack of proper application and documentation of the splint represented a failure to follow these requirements for the resident with a right-hand contracture.