Failure to Provide Timely Medical Device Resulting in Decline in ADLs and Mobility
Penalty
Summary
A resident with a history of sepsis, falls, left knee injury requiring surgery, and major depressive disorder was admitted to the facility and required a left knee immobilizer and right CAM walker boot for safe mobility and transfers. Therapy assessments indicated the resident previously functioned independently but now required assistance for mobility and ADLs due to recent injuries. Both physical and occupational therapy documented that the left knee immobilizer did not fit properly, causing it to slide down and making transfers and ambulation unsafe. As a result, therapy sessions were halted, and the resident was unable to participate in standing activities, ambulation, or transfers out of bed. Despite physician orders for orthopedic and orthotic consultations to obtain a properly fitting knee immobilizer, there was a significant delay in acquiring the device. The resident remained in bed for 12 days, as documented by therapy and nursing staff, due to the absence of a suitable knee immobilizer. During this period, the resident did not receive therapy or assistance with transfers, and documentation indicated that transferring was not applicable or that the resident was totally dependent with at least two-person assistance. The case management team was unaware of the resident's current status and the arrival of a new immobilizer, and there was no documentation of the facility's efforts to expedite obtaining the device. Interviews with staff, the resident, and family confirmed that the resident was confined to bed and unable to participate in therapy or transfers due to the lack of a properly fitting knee immobilizer. The resident expressed feelings of sadness and depression as a result of being bedbound and unable to progress with therapy. The facility's policy required that residents' abilities in ADLs not decline unless unavoidable, but the lack of timely provision of the necessary medical device led to a preventable decline in the resident's mobility and ADL participation.