Failure to Apply Physician-Ordered Palm Protector for Contracture Management
Penalty
Summary
A deficiency was identified when staff failed to follow a physician's order for a resident with a left hand contracture. The resident, who had diagnoses including COPD, chronic respiratory failure with hypoxia, dementia, and depression, was dependent on staff for dressing, grooming, and personal hygiene. The physician's order and care plan specified that a left hand palm protector should be applied at all times or as tolerated, with removal only during activities of daily living and as needed. The care plan also required monitoring for skin irritation, redness, and pain. During observations, the resident was found without the left hand palm protector on multiple occasions, including while sleeping in bed and during feeding assistance. Staff interviews revealed a lack of awareness regarding the application of the device, with a CNA stating that restorative staff applied the device and not knowing its name. The Restorative Director confirmed the importance of following orders for assistive devices to maintain function and prevent further contracture, and stated that nurses and CNAs should monitor the use of such devices. The facility's policy on splint application emphasized proper use for support and contracture prevention.