Failure to Consistently Apply Contracture Prevention Devices
Penalty
Summary
Facility staff failed to ensure that a resident with severe bilateral hand contractures consistently had prescribed devices in place to prevent further contracture and skin breakdown. The resident's care plan and physician orders required continuous use of finger separators on both hands and a palmar grasp splint on the right hand, with staff instructed to monitor and document device placement every shift. Multiple observations over several days revealed that the resident was frequently without any hand devices, both in common areas and in bed, despite the presence of the devices on the bedside table or nightstand. Documentation did not indicate that the resident refused the devices, and there was no evidence that the medical provider was notified of any non-compliance or refusal. Interviews with CNAs, the ADON, and the DON revealed confusion regarding responsibility for device application and documentation. Staff reported that only the treatment nurse or restorative aides applied the devices, and that refusals or skin issues should be documented and reported, but there was no documentation of refusals or notification to nursing or medical staff. The DON confirmed that the lack of device use rendered the intervention ineffective and that the care plan had not been updated to reflect any refusal. The facility's policy required provision of rehabilitative nursing care as ordered, but this was not consistently implemented for the resident in question.