Failure to Provide and Document Ordered Foot Drop Boot for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services as required by facility policy and physician orders. The resident, who had multiple diagnoses including multiple sclerosis, peripheral vascular disease, and contractures, was dependent on staff for activities of daily living and had documented impairments in both upper and lower extremities. Although the care plan included restorative nursing interventions such as passive ROM and splint or brace assistance, it did not document the use of a foot drop boot for the right lower extremity, despite a physician's order for its use. Observations revealed that the resident had two soft heel boots in her room but was not wearing them, stating that only two staff members knew how to apply them correctly and that improper application by others caused her pain. On multiple occasions, the resident was observed in her wheelchair with only socks on her feet, and the boots remained unused on a chair. When offered the boot by the DON, the resident declined and instead accepted a pillow under her feet for comfort. Record review showed that the physician's order for the foot drop boot was not scheduled with a frequency, resulting in its omission from the MAR and TAR, and there was no documentation of administration or refusal of the boot in the EMR. Staff interviews confirmed that the order was not scheduled and therefore not tracked for administration, and that staff relied on the care plan and physician orders for restorative services. The lack of documentation and implementation of the physician's order for the foot drop boot constituted a failure to provide necessary preventive measures for the resident's right foot.