Failure to Provide Timely Contracture Management and Therapy Evaluation
Penalty
Summary
The facility failed to provide timely and appropriate treatment and services to maintain or improve range of motion (ROM) and manage contractures for three residents. For one resident with contractures in both hands and fingers, a physician's order for therapy evaluation for possible brace use was not communicated to the therapy department, resulting in a delay in assessment and intervention. The resident did not receive restorative exercises and was dependent on assistance for daily activities, with no documentation of the therapy order being relayed to the appropriate staff. Another resident with hemiplegia and left-hand contracture had a physician's order for therapy evaluation for a possible brace, but the order was not communicated to the therapy department. As a result, the evaluation was not completed, and the resident did not receive timely assessment or potential treatment to address the contracture. The order was also not discussed during the morning clinical meeting, further contributing to the delay. A third resident developed a pressure ulcer on the left hand due to a contracture, but there was no follow-up with the physician or therapy department regarding contracture management. Staff, including the CNA, were not aware of the contracture, and appropriate devices such as a carrot for hand positioning were not used. The lack of communication and assessment led to missed opportunities for contracture care and prevention of further complications.