Failure to Provide Timely Contracture Management for Resident with Limited ROM
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis, weakness, dysphagia, difficulty walking, pain, and adult failure to thrive was identified as having a range of motion (ROM) limitation on one side and was dependent on staff for transfers. The resident received occupational therapy, during which a palm guard was trialed and tolerated, and further assessment for splinting and palm pad was indicated. Upon discharge from therapy, no recommendations were made for a restorative nursing program for ROM, despite the resident's ongoing needs. Occupational therapy staff reported that therapy was discontinued due to the unavailability of a palm guard, which was subsequently ordered, but therapy did not reevaluate the resident after the device arrived. As a result, timely contracture management was not provided for the resident.