Failure to Follow Care Plan for Splint Application
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan for a resident with a history of cerebrovascular accident (CVA) resulting in left-sided hemiplegia and hemiparesis. The care plan, initiated due to decreased mobility and function, directed staff to apply a left wrist brace overnight to prevent contractures. However, the clinical record lacked documentation of the splint's application or removal, and observations confirmed the resident was not wearing the splint as required. The resident reported that both he and staff would forget to apply the splint at night, and also noted that staff did not consistently use the recommended platform walker for transfers. Further interviews revealed that the resident did not always receive the splint, denied refusing it, and stated that some staff were not trained in its application. Therapy notes indicated ongoing goals for consistent splint use, and staff confirmed the resident experienced pain and tightness, supporting the need for the splint. The DON was unable to provide documentation of the splint's use or any record of refusals, and acknowledged that the intervention was removed from the care plan without clear evidence of resident refusal or clinical justification documented at the time.