Failure to Provide Ordered Neck Support for Resident with Contractures
Penalty
Summary
A resident with quadriplegia, aphasia following nontraumatic intracranial hemorrhage, and dysphagia following cerebrovascular disease was admitted to the facility and identified as being at risk for contractures, specifically a neck flexion contracture. Physician orders directed staff to apply a neck pillow for head support, and the resident's care plan noted limited range of motion and the need for assistance with activities of daily living. However, there was no documentation in the care plan regarding the neck pillow intervention. Multiple observations over two days revealed that the resident was not provided with the neck pillow, and the device was not present in the resident's room. Staff interviews confirmed that the resident was supposed to have a neck pillow for support, and both the ADON and DON stated that staff were expected to follow physician orders and care plans unless the resident refused, with refusals to be documented. The facility failed to provide the required equipment to prevent further decrease in range of motion, as ordered and care planned.