Failure to Accurately Document and Implement Physician Orders for Splint Care
Penalty
Summary
The facility failed to maintain accurate medical records and ensure proper implementation of physician orders for a resident requiring a right elbow splint. The resident, who had a history of stroke, hemiplegia, vascular dementia, and an acquired absence of the right leg below the knee, was dependent on staff for most activities of daily living. Despite a physician's order for the resident to wear a right elbow splint during the daytime for four to six hours daily, multiple observations over several days showed the resident was not wearing the splint. The resident reported that staff did not apply the splint and that an aide was unaware of its location. Review of the Medication Administration Record revealed that nursing staff, specifically an LPN, documented that the splint was applied on several days when, in fact, the resident was not wearing it. The LPN admitted to documenting the application of the splint without verifying with the CNA or directly observing the resident. The unit manager and DON confirmed that CNAs were responsible for applying the splint and nurses were expected to ensure compliance with orders and provide accurate documentation. The inaccurate documentation and lack of verification led to the deficiency in maintaining medical records according to professional standards.