Failure to Notify Physician and Apply Ordered Splint
Penalty
Summary
Licensed nursing staff failed to follow a physician's order for a resident who required left elbow, left hand, and bilateral knee splints to be applied for three to four hours daily, seven days a week, as tolerated. The resident, who had diagnoses including quadriplegia, contractures, and a history of traumatic amputation, was dependent on staff for all activities of daily living and had significant cognitive impairment. Observations and interviews revealed that while the elbow and knee splints were applied, the left hand splint was not put on for at least two weeks, and possibly longer, due to it being missing. Staff interviews indicated a lack of awareness or misunderstanding of the physician's order, with one nurse stating there was no order for a left hand splint and another confirming the splint had not been applied for an extended period. Documentation in the resident's medical record did not reflect the omission of the left hand splint, nor was there evidence that the physician or therapy department had been notified about the missing or unused splint. The Director of Nursing confirmed that such omissions should be documented and reported to the physician and family, but this did not occur. A review of facility policy confirmed the requirement to notify the physician and resident representative of significant changes or the need to alter treatment. Despite this, there was no documentation or notification regarding the failure to apply the left hand splint as ordered, constituting a deficiency in following physician orders and in communication regarding changes in the resident's care.