Failure to Apply Prescribed Knee Braces for Dependent Resident
Penalty
Summary
A deficiency was identified when staff failed to apply prescribed knee braces to a resident with significant cognitive and physical impairments. The resident, who had diagnoses including dementia, diabetes, pain, and a history of falls, was dependent on staff for all activities of daily living and unable to communicate needs. The care plan specified that the resident was to wear knee extension braces daily for as long as tolerated, and there was no documentation of the resident refusing the braces. However, during multiple observations, the resident was seen in a Broda chair without the knee braces applied. Interviews with nursing staff and review of facility policy revealed that all nursing staff had access to the resident's care plan and were responsible for ensuring the application of special equipment such as braces. Staff confirmed that any refusal to use such equipment would be documented, but no such documentation existed for this resident. The facility's restorative nursing policy emphasized the importance of promoting residents' optimal function through proactive care planning and monitoring, yet the required intervention of applying knee braces was not carried out as directed.