Failure to Apply and Document Prescribed Positioning Devices for Resident with Contracture
Penalty
Summary
The facility failed to ensure that a positioning device was consistently applied for a resident with a right-sided contracture following a stroke. The resident's care plan and Kardex specified that a right upper extremity hand splint should be applied for four hours daily in the morning and a carrot splint should be used as tolerated during the day and night. However, during multiple observations, the resident was seen without any splint or positioning device on his right hand. Interviews with staff, including a CNA and an LPN, revealed that they were unaware of any splint or device to be used for the resident, and the CNA reported never having seen a splint on the resident in her seven months at the facility. Further review of the resident's medical record showed no documentation that the splint or carrot device had been applied as directed in the care plan and Kardex. The Senior Director of Nursing confirmed that the care plan and Kardex included instructions for splinting, and that staff should have documented the application of these devices, but there was no such documentation present. This lack of consistent application and documentation of the prescribed positioning devices constituted a failure to provide appropriate care to maintain or improve the resident's range of motion.