Failure to Provide and Document Required Splint Application and ROM Exercises
Penalty
Summary
A deficiency was identified when a resident with a history of epilepsy, hemiplegia, and hemiparesis following a stroke was not provided with the required application of splints and range of motion (ROM) exercises as ordered. Observations showed the resident in bed without the prescribed splints, and the splints were later found stored in a dresser drawer. The resident reported that staff were not applying the splints, stating that they were too busy. Interviews with a CNA and a registered nurse confirmed that splints were not being applied and ROM exercises were not being performed. The registered nurse indicated that CNAs were responsible for these tasks, but there was no restorative nurse or aides assigned to the program at that time. A review of the resident's electronic medical record revealed no documentation of splint application or ROM exercises, nor any record of refusals, for several weeks. The resident's care plan and Kardex included specific instructions for splint use and ROM exercises, but these interventions were not carried out or documented. The facility's policy required daily documentation of restorative care and interventions, but this was not followed for the resident in question.