Failure to Apply Physician-Ordered Palm Roll Splint for Contracture Management
Penalty
Summary
A resident with a history of diabetes, paraplegia, and hypertension was admitted to the facility and had documented limited range of motion. The resident was discharged from therapy with instructions to wear a resting hand splint on the left hand for up to 8 hours. Subsequently, a physician's order was issued for the resident to wear a palm roll splint for 4 hours in the morning and 4 hours in the evening for contracture management. However, review of the resident's documentation showed no evidence that the palm roll splint was applied as ordered. Multiple observations over several days revealed that the resident was consistently found without the palm roll splint on the left hand, despite the splint being present in the room or on the bedside stand at times, and at other times not visible in the room. During an interview, the Director of Nursing confirmed that the resident did not have the palm roll splint applied per physician's orders. This failure to provide the ordered treatment and services for contracture management constituted a deficiency in care for the resident with limited range of motion.