Failure to Provide Prescribed Splinting and ROM Interventions for Resident with Limited Mobility
Penalty
Summary
A deficiency was identified when a resident with a persistent vegetative state and contractures in both wrists did not receive appropriate treatment and services to maintain or improve range of motion (ROM) as care planned. The resident was supposed to have left and right wrist and knee splints applied daily for six hours, along with passive ROM exercises. However, multiple observations over several days revealed that the resident's hand splints were found on the bedside table or in the closet, and the resident was not wearing the knee splints while in bed, with her knees drawn up to her chest. Record review showed that the resident's care plan and restorative monthly summaries documented the need for bilateral knee and hand splints, as well as daily passive ROM. Despite this, interviews with staff revealed a lapse in the implementation of the restorative program. The Restorative Aide stated that restorative services, including splinting, had not been provided recently and were scheduled to resume the following week. The Physical Therapist and Director of Rehab confirmed that after the resident was discharged from therapy, responsibility for splinting was to be transferred to restorative staff, but this transition did not occur as expected. Further interviews indicated a breakdown in communication and process between therapy, restorative nursing, and direct care staff. The Unit Manager/Restorative Nurse reported that restorative programs would not begin until all necessary information was placed in the restorative binder, and there was confusion regarding the receipt of communication forms for the resident's splinting needs. The DON acknowledged that restorative programs should be initiated promptly but was unclear on how this was communicated to staff. As a result, the resident did not receive the prescribed splinting and ROM interventions, contrary to the facility's policy and care plan.