Failure to Implement Physician-Ordered Hand Roll for Contracture Prevention
Penalty
Summary
A deficiency was identified when nursing staff failed to implement a physician-ordered hand roll for a resident with right hand contractures, as recommended by the therapy department. The resident, who had diagnoses including muscle weakness, dementia, and arthritis, was severely cognitively impaired and dependent on staff for activities of daily living. Multiple observations over several days showed the resident in bed with the right hand closed in a fist position and without the prescribed hand roll in place, despite clear instructions posted at the bedside and orders for its use at night. Review of the resident's records revealed a physician's order for passive range of motion (PROM) to the right hand followed by application of a hand roll prior to bedtime, to be removed in the morning. The care plan and therapy documentation also specified the need for the hand roll, and staff had been educated on the wear schedule and proper application. However, the Medication Administration Record and Treatment Administration Record did not reflect the use of the hand roll, and the physician's order lacked detailed directions for use. Interviews with nursing staff and CNAs indicated a lack of awareness or understanding regarding the hand roll order and its implementation. Some staff were unsure of the wear schedule or had not received education on the device, while others questioned the incomplete directions in the order. Despite education efforts and visual reminders, the resident was repeatedly observed without the hand roll as ordered, resulting in a failure to provide appropriate care to maintain or improve range of motion and prevent further contracture.