Failure to Ensure Application of Ordered Palm Protector for Resident with Contracture
Penalty
Summary
A deficiency occurred when a resident with a physician's order and care plan for a left hand palm protector was repeatedly observed without the device in place while in bed. The resident's left hand was contracted in a closed fist position, with fingers pressing into the palm, and the palm protector was not applied as ordered during multiple observations. Staff interviews revealed a lack of awareness regarding the resident's need for the splint, with one agency CNA stating she was unaware of the device and the restorative nurse indicating she did not know the resident was without it and was unsure of its location. The resident's care plan and physician's order specified the palm protector should be on during AM cares and removed for hygiene and bathing, with monitoring for compliance and documentation of refusals or unscheduled removal, but these interventions were not followed as observed.