Failure to Apply and Document Physician-Ordered Splints for Residents with Limited Mobility
Penalty
Summary
The facility failed to follow physician's orders and its own policy regarding the application of splints for two residents with significant physical and cognitive impairments. For one resident with cerebral palsy, traumatic brain injury, and severe cognitive impairment, there was a physician's order for specific hand and elbow splints to be worn from morning care until bedtime as tolerated. For another resident with hemiplegia, Parkinson's disease, and severe cognitive impairment, the care plan indicated the use of a left-hand splint to prevent skin breakdown and maintain hand position. However, repeated observations throughout the day showed that the resident's contracted hand was not fitted with the prescribed splint at any time. Interviews with staff, including the Rehab Director and an LPN, confirmed that the splint was not applied as ordered and that documentation of splint application was inconsistent or absent. The facility's policy required staff to apply splints according to therapy and physician instructions, inspect the skin, and document the application, but these steps were not followed. The inaction of staff in not applying the splints as ordered and failing to document their use led to the deficiency in care for both residents.