Failure to Apply Physician-Ordered Hand Splints for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, muscle contracture, and hypothyroidism did not receive physician-ordered bilateral resting hand splints as prescribed. The facility's policy required nursing staff to follow physician orders and recommendations for splinting devices, but documentation in the clinical record lacked evidence that the splints were applied according to the specified schedule. Observations on multiple occasions confirmed that the resident was not wearing the resting hand splints at times when they should have been, as per the physician's order. During interviews, an LPN confirmed that the resident did not have the splints on and acknowledged that they should have been applied according to the physician's instructions. The failure to follow the prescribed splinting schedule and lack of documentation demonstrated that the resident did not receive appropriate treatment and services to prevent further decrease in range of motion, as required by federal and state regulations.
Plan Of Correction
Therapy replaced bilateral missing hand splints of R120 on 6/26/25. Therapy will do an initial audit of all residents with orders for splints to ensure all are available for use. Nursing staff will be educated on informing therapy immediately if resident splints are missing or unavailable. The Director of Therapy will continue to educate all nursing staff/therapy staff on applying resident splints per physician orders/splinting schedule. The Director of Nursing/designee will educate all nursing staff on informing therapy immediately if resident splints are missing, damaged, or unavailable. The Director of Therapy/designee will conduct a weekly audit to ensure all splints are available to residents. A Unit Licensed Practical Nurse will conduct a daily audit to ensure all splints are being worn per the resident schedule. Daily audits will continue for four weeks, then weekly for four weeks, then monthly for four months, then quarterly. Results of these audits will be reviewed at the Quality Assurance Committee monthly for review until audits meet 100% compliance for three consecutive quarters. The Director of Nursing/designee will be responsible for compliance. Completion Date: 7/31/25