Failure to Apply Physician-Ordered Splints for Resident with Limited ROM
Penalty
Summary
A resident with a history of respiratory failure and a dislocated right shoulder was admitted to the facility and had physician orders for the application of bilateral hand splints, a right elbow splint, and bilateral ankle-foot orthosis (AFO) boots to be applied daily, six days a week. The resident was dependent on staff for personal hygiene, showering, and dressing, and had limited range of motion in both upper and lower extremities. Observations over two days revealed that the resident did not have the full set of splints applied as ordered by the physician. During interviews, the Restorative Nurse Assistant (RNA) acknowledged not placing all the required splints on the resident and admitted to inconsistency in following the physician's orders. The RNA specifically noted that the left-hand splint and right elbow splint were missing. A Licensed Vocational Nurse (LVN) also confirmed the absence of the required splints and stated that RNAs were responsible for reporting missing devices. Facility policies reviewed indicated that assistive devices and equipment should be maintained and supervised to support resident mobility, safety, and independence.