Failure to Obtain Splint Orders and Inadequate Assessment Prior to Hospital Transfer
Penalty
Summary
The facility failed to obtain a physician order for the use of a splint and did not properly assess or address a resident's condition prior to hospital transfer. For one resident with contractures of the left elbow and both hands, observations revealed the absence of splints or braces despite occupational therapy recommendations for orthotic support and the use of towel rolls. The occupational therapist confirmed that recommendations were made and communicated verbally to staff, but no formal physician order was documented, and the Director of Nursing acknowledged the lack of orders to address the contractures. In a separate incident, another resident was transferred to the hospital after experiencing pain and trouble breathing. Documentation showed that only one progress note was written in the relevant timeframe, and there was no record of vital signs being obtained or documented prior to the transfer, despite facility expectations. While pain medication was administered, there was no documentation indicating that the complaint of trouble breathing was addressed. The Director of Nursing confirmed the absence of vital sign documentation and the lack of follow-up on the respiratory complaint.