Failure to Provide Ordered Palmar Cushion for Resident with Contractures
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis, and contractures following a cerebral infarction was not provided with appropriate treatment and services to maintain or improve range of motion (ROM) in accordance with physician orders. The resident had an order for a palmar cushion to be applied to the left hand at all times, except during hygiene, to prevent further contractures. Observations on multiple occasions revealed that the resident did not have the palmar cushion in place, and the resident reported not having had the cushion for weeks, despite feeling more comfortable with it. Nursing staff were unaware of the order and had not been applying the cushion, and the order was not reflected on the medication administration record (MAR) due to a lack of proper entry into the system. Interviews with staff indicated a lack of awareness and communication regarding the resident's need for the palmar cushion, with responsibility for its application being unclear between therapy and nursing. The care plan and physician orders specified the need for the cushion, but these were not consistently followed. Additionally, the facility did not have a current policy addressing the prevention and treatment of contractures, contributing to the failure to provide the required care and services to maintain the resident's ROM.