Failure to Apply Prescribed Hand Splint for Resident with Contracture
Penalty
Summary
Facility staff failed to ensure the use of a hand splint for a resident with a left-hand contracture and hemiplegia, as specified in the resident's care plan. The care plan, which was last revised in October 2024, required staff to assist with the application of supportive devices, including splints, and to perform skin checks every shift. However, during multiple observations, the resident was seen without a splint or any supportive device on the affected hand, and there was no documentation of such interventions in the Treatment Administration Record (TAR). Additionally, the resident had not received any occupational therapy screening or evaluation since August 2024, despite ongoing limitations in range of motion as documented in the Minimum Data Set (MDS) assessment. The lack of follow-up therapy and absence of the prescribed supportive device indicate that the facility did not implement the care plan interventions intended to maintain the resident's ability to perform activities of daily living.