Failure to Implement Physician-Ordered Palm Protector for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's left palm protector was implemented as ordered to prevent skin breakdown and deformity. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle weakness, and vascular dementia, had a physician's order for a left palm protector to be applied in the morning and removed at bedtime, with skin integrity checks twice daily. Documentation in the medical record indicated the palm protector was applied as ordered, and the care plan included this intervention. However, during observation, the resident was found with a contracted left hand and no palm protector in place, and the resident confirmed that the device was supposed to be worn during the day. A CNA also confirmed the palm protector was not in place as ordered and applied it at that time. Further interviews revealed that staff were not consistently aware of the timing for removal of the palm protector, with one CNA stating she was unaware it was to be removed at bedtime. Additionally, the facility did not have a policy regarding the use of palm protectors.