Failure to Document and Assess Skin During AFO Application for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve range of motion (ROM) for a resident with contractures in both lower extremities. Despite a physician's order for the application of bilateral ankle-foot orthoses (AFOs) for four hours daily, five times a week, the order was not consistently followed. Documentation was lacking regarding the exact times the AFOs were applied and removed, and there was no evidence that skin assessments were performed or recorded when the AFOs were in use. The resident's care plan addressed the use of AFOs to prevent decline in ROM, but did not include interventions for skin assessment during device application. Interviews with restorative nursing assistants (RNAs), a licensed vocational nurse (LVN), and an occupational therapist (OT) confirmed that while the AFOs were applied, there was no documentation of the timing or skin assessments. The facility's policy on restorative nursing care emphasized maintaining good body alignment and proper positioning, but did not specify skin assessment procedures. The director of nursing (DON) verified the findings, confirming the lack of documentation and absence of skin assessment protocols related to the use of AFOs for the resident.