Failure to Implement Contracture Management Orders for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with a history of morbid obesity, protein-calorie malnutrition, and a PEG tube, who was bed-bound and had limited range of motion (ROM) in all extremities, did not receive appropriate ongoing contracture management. The resident had previously received Physical Therapy (PT) and Occupational Therapy (OT) services for contracture management, with OT goals to prevent further contractures. Upon discharge from therapy, recommendations were made for nursing staff to apply splints daily and remove them at night. However, there was no evidence that these recommendations were entered as orders in the electronic medical record (EMR), nor were they reflected in the resident's care plan. During the survey, staff interviews revealed that neither the Director of Rehab nor the Occupational Therapist could confirm when the last quarterly evaluation was completed for the resident, and they were initially unable to clarify who was responsible for entering therapy discharge orders into the EMR. It was later confirmed that the orders for nursing to implement the OT discharge recommendations were never placed, resulting in a lack of follow-through on the prescribed contracture management interventions for the resident.