Failure to Apply and Document Splint Use for Residents with Contractures
Penalty
Summary
The facility failed to ensure that splints were applied as ordered for two residents with contractures and limited range of motion. One resident with a history of stroke and left-sided paralysis was observed multiple times without his prescribed left hand splint, despite care plan interventions specifying daily use as tolerated. The resident reported that staff did not apply the splint or perform exercises for his contracted arm, and there was no documentation of refusals or splint application in the resident's records for the relevant period. The Director of Nursing confirmed that if there was no documentation, the intervention was not performed, and the resident was only referred to therapy after the deficiency was identified. Another resident with hemiplegia and reduced mobility was also found without a splint, and there were no physician orders for splint placement in the records. The care plan noted occasional refusals to wear the splint, but there was no documentation of such refusals. The resident stated he would wear the splint if staff assisted, but staff tasks did not include splint application. The Director of Nursing confirmed that splint use should be documented and that splints are intended to prevent worsening contractures, but no consistent documentation or evidence of splint application was found for this resident.