Failure to Provide Contracture Management and Accurate Documentation
Penalty
Summary
A deficiency occurred when a resident with a left hand contracture was not provided with her prescribed hand splint/hand carrot as ordered by the physician and outlined in her care plan. Multiple observations on 6/9/2025 revealed the resident was not wearing the splint, and there was no splint present in her room. The resident was unable to apply the splint herself and was dependent on staff for this intervention. Interviews with staff confirmed that the Restorative Aide, who is responsible for applying the splint, was not present that day, and other staff did not ensure the splint was applied. There was also confusion among staff regarding who was responsible for applying the splint in the absence of the Restorative Aide. Documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated that the splint was applied as ordered, but direct observation and staff interviews confirmed this was not the case. There was no documentation of the resident refusing the splint, and staff were unaware of the need to document refusals or the absence of the splint. The care plan and physician's orders specified the use of the splint daily, with skin checks before and after application, but these interventions were not consistently implemented or documented. The resident's medical record indicated a history of contractures, muscle weakness, and dependence on staff for activities of daily living. Despite clear orders and care plan interventions for contracture management, the facility failed to ensure continuity of care when the designated Restorative Aide was off duty. This resulted in the resident not receiving the prescribed intervention to maintain or improve range of motion, and the lack of accurate documentation further contributed to the deficiency.