Failure to Implement Contracture Prevention Interventions
Penalty
Summary
The facility failed to implement physician-ordered interventions to prevent the deterioration of contractures for a resident with significant musculoskeletal impairments. The resident, who had diagnoses including anoxic brain damage, contractures in both hands, elbows, and shoulders, and chronic pain, was dependent on staff for all activities of daily living and had severely impaired cognition. The care plan included placing washcloths in both hands every shift to prevent fingers from clenching, cleansing and drying hands before application, and providing range of motion (ROM) as indicated. Despite these orders, multiple observations over several days revealed that the washcloths were not in place and the resident's hands remained closed-fisted. Staff interviews confirmed that the washcloths had not been applied as ordered, and the care plan interventions were not consistently followed. The resident was also noted to be unable to tolerate passive ROM due to distress, with care plans adjusted to clean hands as tolerated and monitor for skin breakdown. However, the primary intervention to prevent further contracture—placement of washcloths—was not implemented, as verified by both direct observation and staff acknowledgment.