Failure to Provide Prescribed Splint for Resident with Limited ROM
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia and severe contractures following a stroke did not consistently receive care as ordered to maintain range of motion (ROM) in the left upper extremity. The resident's care plan and provider orders specified the use of a hand splint on the left arm each morning, to be worn for up to six hours and removed in the afternoon, with hand hygiene performed before application. However, multiple observations over several days revealed that the resident was not wearing the splint at any observed time. Interviews with staff indicated a lack of awareness regarding the splint order, with some staff only aware of the use of blue boots for the resident's legs and feet. Documentation systems did not include a prompt for splint application, and the splint itself had reportedly been missing for months without follow-up or replacement. Further, there was no evidence in the medical record of physician notification regarding the resident's reported pain with splint use, nor were there any therapy orders in place during the relevant period. Therapy staff confirmed the resident had not been on their caseload for splint management since a previous year, and the DON acknowledged that missing or painful splints should prompt provider notification and therapy involvement. The facility was unable to provide a splint usage policy when requested. These actions and inactions resulted in the resident not receiving the prescribed intervention to maintain or improve ROM, as required by their care plan and provider orders.