Failure to Apply Ordered Hand Splint for Resident with Contracture
Penalty
Summary
Facility staff failed to provide adequate care to prevent complications from hand contractures for a resident with a history of left-sided hemiplegia, hemiparesis, and a left wrist contracture. The resident had an active physician order for a left resting hand splint to be applied daily after morning care and removed after lunch, with hand hygiene and passive range of motion (PROM) of digits, as well as a skin check in the evening. Despite these orders, multiple observations by surveyors on different days revealed that the resident did not have the left hand splint in place, and no splint was visible in the resident's room. The resident reported that staff did not regularly apply the splint and was unable to locate it when asked. Review of the Treatment Administration Record (TAR) showed that staff documented the application of the splint daily, which was inconsistent with surveyor observations and the resident's statements. Interviews with nursing and rehabilitation staff confirmed that the splint was ordered to minimize further contracture and reduce pain, but staff could not account for the splint's whereabouts or provide evidence that it was being used as ordered. The lack of splint application and inconsistent documentation indicated a failure to follow physician orders and provide necessary care to maintain or improve the resident's range of motion.