Failure to Apply Ordered Foot Drop Brace for Contracture Prevention
Penalty
Summary
A deficiency was identified when a resident with a history of foot drop and limited mobility did not receive the ordered application of a foot drop brace (Ankle-Foot Orthosis, AFO) for contracture prevention. The resident reported not having worn the brace for about a month, and observations confirmed the brace was not in use, despite being present in the room. The resident's medical record included an active order for the brace to be worn at bedtime and removed in the morning, with skin checks at each application and removal. However, a new order to hold the brace due to impaired skin integrity was only placed recently, and there was no documentation of a wound or change in condition on the resident's left ankle prior to this order. Interviews with facility staff revealed a lack of awareness regarding the resident's need for the brace and the presence of any wounds on the ankle. The Rehab Director stated that the brace was withheld due to a supposed ankle wound, but no such wound was documented in the medical record or observed during a physical assessment. Additionally, the LPN responsible for the resident was unaware of the brace order and only knew of a sacral wound, not an ankle wound. The administrator was informed of the concern that the resident had not been wearing the ordered brace and that staff were not aware of the order.