Failure to Provide Prescribed Range of Motion Device
Penalty
Summary
A resident with a history of epilepsy, depression, and cerebral infarction resulting in right-sided hemiplegia and hemiparesis was identified as having an activities of daily living (ADL) self-care deficit. The resident's care plan included an intervention to place a rolled cloth in her right hand as tolerated to address limited range of motion (ROM). Medical record review and observations on multiple occasions revealed that the resident did not have the prescribed rolled cloth or any similar device in her right hand. During interviews, the resident confirmed that staff previously placed a carrot-shaped device in her right hand, but it had been discarded and not replaced. A registered nurse acknowledged that the resident should have had a rolled cloth in her hand but did not. The therapy manager confirmed that therapy had recommended the use of a cloth carrot in the resident's right hand and was unaware that it had been lost. These findings demonstrate that the facility failed to ensure the prescribed ROM device was in place for the resident.