Failure to Apply Splint Devices as Ordered for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that splint devices were applied as ordered for a resident with significant physical impairments. Multiple observations over several days showed that the resident, who had diagnoses including traumatic brain injury, quadriplegia, and respiratory failure, was not wearing the prescribed hand or elbow splints while in bed. The resident was dependent on staff for all activities of daily living and had impaired mobility in both upper and lower extremities. Despite physician orders specifying that bilateral hand splints should be applied in the morning for three hours, followed by bilateral elbow splints for three hours, the devices were not observed in use during multiple checks. The splints were found stored in the resident's room rather than being applied as ordered. Interviews with staff and review of documentation revealed discrepancies between recorded care and actual practice. Nursing staff and CNAs documented in the electronic records that the splints were applied daily, but both a nurse and a CNA admitted during interviews that the resident had not worn the splints for a long time. The CNA clarified that her documentation referred to performing passive range of motion (PROM) exercises, not the application of splints, and that she had not applied the devices as ordered. The facility's policy required following physician orders, but this was not adhered to in the resident's care.