Failure to Provide Prescribed Foot Orthosis for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when a resident with a history of muscle wasting, atrophy, and right-sided weakness following a hemorrhagic stroke was not provided with the prescribed Pressure Relief Ankle Foot Orthosis (PRAFO) boot for their right lower extremity. The physician's order and care plan specified the use of the PRAFO boot for two hours, three times a week, to support, align, and protect the resident's right foot. However, during multiple observations and interviews, it was confirmed that the resident did not have the PRAFO boot available or in use, and instead, a soft heel protector was used for an entire week because the PRAFO boot could not be located. The Restorative Nursing Assistant (RNA) did not notify nursing or rehabilitation staff about the missing device or arrange for a replacement, and acknowledged that the evaluation of the resident's use of the PRAFO boot was inaccurate due to the substitution. The lack of the correct orthotic device was confirmed through record review, staff interviews, and direct observation. The Director of Nursing (DON) stated that the appropriate steps were not taken to locate or replace the PRAFO boot, and the facility's policy indicated that splints are used to prevent contractures and protect joint alignment. The manufacturer's guide for the PRAFO boot also emphasized its role in supporting and positioning the lower leg, ankle, and foot, and minimizing pressure areas. The failure to provide the prescribed orthosis as ordered constituted a deficiency in care for the resident.