Failure to Apply Prescribed Hand Splints Resulting in Worsening Contractures
Penalty
Summary
A resident with a history of right femur fracture, diabetes mellitus, and osteoarthritis was admitted to the facility and assessed as requiring supervision and maximal assistance for activities of daily living. The resident had physician orders and occupational therapy recommendations for the application of resting hand splints to both hands for two hours daily, five times a week, to address impairments and prevent contractures. However, during observations, the resident was seen without the prescribed hand splints, and both hands were noted to be in a contracted position. The Restorative Nurse Assistant (RNA) reported being unable to apply the splints because they were missing. Further review and interviews revealed that the resident experienced pain during passive range of motion exercises, and the occupational therapist determined that the right hand contracture had worsened, with a new contracture developing in the left hand. The facility's policy required the provision of specialized rehabilitative services as assessed in the comprehensive care plan, but the prescribed intervention of hand splint application was not carried out due to the unavailability of the splints.