Failure to Apply Prescribed Hand Splint for Resident with Contractures
Penalty
Summary
A resident with a history of hemiplegia, contractures, and other significant medical conditions was admitted to the facility and received occupational therapy (OT) services, including the use of a left-hand splint to address contractures. Upon discharge from OT, recommendations were made for the continued daily application of the orthosis for up to six hours, with regular monitoring. However, subsequent observations revealed that the resident was not wearing the splint, and both the resident and staff reported that the splint had not been applied. Multiple staff interviews indicated a lack of awareness of any current orders for the splint, and the splint itself could not be located in the resident's room. Further review showed that there was no documentation or in-service training provided to nursing staff regarding the splint application after OT discharge. The electronic health record did not contain active orders for the splint, and staff were unclear about the process for continuing splint use after therapy ended. The breakdown in communication between therapy and nursing staff resulted in the resident not receiving the recommended intervention to maintain or improve range of motion, as prescribed by OT.