Failure to Ensure Proper Use of Splint 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, as required by regulation. The resident, who had a history of stroke and elevated blood pressure, had a physician's order and care plan in place for a left hand splint to be worn at all times, with removal only for care and skin monitoring. Despite these orders, multiple observations over two days revealed that the resident's left hand splint was not in place, and the resident confirmed that staff had not applied the splint. The splint was observed in a basket on the resident's bedside dresser during this time. Documentation in the Medication Administration Record (MAR) indicated that the splint was signed off as being on during each shift, except for a few instances marked as refused by the resident. However, interviews with facility leadership revealed confusion regarding the status of the splint order, with the DON referencing a progress note from two months prior about the splint being on hold due to swelling, but no current orders or documentation supporting discontinuation of the splint prior to the most recent therapy note. Occupational therapy documentation indicated the splint should continue until therapy was discontinued, and there was no evidence of a physician order to discontinue the splint before July. This discrepancy between documentation, staff actions, and physician orders led to the deficiency.
Plan Of Correction
Preparation and submission of this plan of correction does not constitute an admission of, or agreement with, it is required by State and Federal Law. It is executed and implemented as a means to continuously improve the quality of care to comply with the state and federal requirements. 1. Resident 48 had no ill effects from the cited past deficient practice. During the survey, Attending Physician was contacted for clarification, order was obtained to remove splint on left hand, care plan was updated. 2. To identify others with the likelihood to be affected, the DON/designee completed a house-wide audit to identify all residents ordered splints. Assessments were completed on all residents identified, to ensure any splints ordered are in place and not causing skin impairment. Splint was reviewed with the therapy dept and attending physician, plan of care was updated reflecting any further recommendations received. 3. To prevent a future reoccurrence, the DON/designee will educate all nursing staff to ensure documentation completed on splinting for a resident reflects the plan of care observed in place, and follows physician orders. If splint is held by physician, order will be transcribed to current plan of care ordered. 4. To monitor and maintain ongoing compliance, the DON/designee will audit 5 random residents with splints to ensure the resident is free of skin impairment related to splint, and the documentation completed reflects plan of care observed, weekly x 4 weeks and then monthly x 2. Any inaccurate findings will be corrected immediately, and findings will be reported to the QA committee monthly, for any further recommendations.