Failure to Apply Physician-Ordered Splint for Resident with Hand Contracture
Penalty
Summary
A resident with a right-hand contracture was observed on multiple occasions without the prescribed splint or palm guard in place, despite physician orders requiring continuous use of the device with removal only for skin checks and hygiene. Observations showed the resident in bed with the right hand contracted and no splint or washcloth present. Review of the resident's medical record confirmed an active order for a right-hand palm guard with finger separators and a rolled towel for the elbow crease, to be used 24 hours a day as tolerated. The occupational therapy discharge summary indicated that the resident had previously met a goal of tolerating the palm guard for four hours daily, and a restorative program was implemented with staff training. However, interviews with staff revealed a lack of clarity regarding responsibility for applying the splint, with the DON stating that therapy staff put on the splints and floor staff monitored for skin checks. During an assessment, an LPN did not apply the splint after examining the resident's hand. Therapy services for the resident had ended, with the restorative program intended to continue, but the splint was not consistently applied as ordered.