Failure to Provide Prescribed Splints and Hand Rolls for Resident with Contractures
Penalty
Summary
A resident with diagnoses including traumatic hemorrhage of the cerebrum, hemiplegia, aphasia, and bilateral hand contractures was identified as having functional limitations in range of motion (ROM) in both upper and lower extremities, with severely impaired cognitive skills for daily decision making. The resident's care plan and physician orders specified the use of an elbow splint for the right elbow and bilateral hand rolls to address contractures and impaired mobility. Despite these documented orders and care plan interventions, multiple observations over two consecutive days revealed that the resident did not have the prescribed hand rolls or elbow splint in place at any time. Interviews with both an LPN and a CNA confirmed the absence of these devices, with the CNA noting that the splints had not been present during her previous shifts. The DON was notified of these findings, confirming that the facility failed to provide the required splints and hand rolls as ordered and care planned for the resident.