Failure to Provide Ordered Restorative Nursing Treatments
Penalty
Summary
The facility failed to provide restorative nursing treatment as ordered for one resident with a history of left-sided hemiplegia, left hand contracture, and left ankle contracture. Physician orders and the resident's care plan required daily passive range of motion (PROM) exercises and the application of a left ankle-foot orthosis (AFO) and a left resting hand splint for four hours each day. Documentation and interviews revealed that from 5/16/2025 to 5/22/2025, the resident did not receive the ordered application of the left AFO, and from 5/20/2025 to 5/22/2025, the left resting hand splint was also not applied as required. Observations confirmed that the resident was not wearing the prescribed splint or AFO during multiple visits, and both the restorative nursing assistant and certified nursing assistant were unable to explain why the devices were not applied. The resident reported not having the devices on for several days, despite usually wearing them. The Director of Physical Therapy emphasized the importance of following physician orders to prevent further decline in range of motion and foot drop. Facility policy required restorative nursing care to be provided as outlined in the resident's plan of care, which was not followed in this instance.