Failure to Document and Assess Skin During Splint Use for Resident with Limited ROM
Penalty
Summary
The facility failed to follow a physician's order for the application of a left knee extension splint for a resident with limited range of motion (ROM). The order specified that the splint should be applied to the resident's left knee five times a week for up to five hours a day or as tolerated. However, there was no documentation of the exact times when the splint was applied and removed. Additionally, the care plan and medical record did not include or document any skin assessments when the splint was in use, despite the resident having hardware (screws) in the leg and being at risk for skin issues. Interviews with staff confirmed that while the splint was applied as ordered, there was no record of skin assessments being performed or documented during its use. The facility's policy on restorative nursing services required care to promote safety and independence, but the lack of documentation and omission of skin assessments represented a failure to provide appropriate care to prevent a decline in ROM and potential skin complications. The Director of Nursing verified these findings during the survey.