Failure to Document and Manage Use of Palm Guards for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. Specifically, a resident with diagnoses including difficulty swallowing, anoxic brain injury, and muscle weakness was observed wearing palm guards on both hands. However, a review of the clinical record did not reveal a physician's order for the palm guards, nor was there documentation in the care plan regarding their use and management. Further investigation, including staff interviews, confirmed that the facility did not obtain a physician's order for the palm guards and failed to include their care and management in the resident's care plan. This lack of documentation and oversight was in violation of the facility's own Restorative Nursing policy, which requires physician orders and care plan documentation for restorative devices such as splints or braces.