Failure to Follow Up on Contractured Wrist Care
Penalty
Summary
The facility failed to provide appropriate follow-up care and monitoring for a resident with a contractured left wrist. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, muscle weakness, and other significant medical conditions, was observed to have a visibly contractured left wrist. Despite this, there were no active physician orders, care plan interventions, or documented goals addressing the contracture. The care plan did not include any positioning or splinting interventions, nor were there measures to prevent injury from fingernails pressing into the palm. Therapy documentation showed that the resident declined a wrist splint on one occasion, but there was no evidence of follow-up or reassessment by therapy until prompted by a surveyor's inquiry months later. Interviews with facility leadership confirmed that there was no policy or process in place to ensure therapy follow-up after an initial refusal of a splint. Additionally, physician documentation inaccurately identified the affected arm, and no further documentation was available to address the contracture. The lack of ongoing assessment and intervention resulted in the resident's contracture not being properly managed.