Failure to Apply Prescribed Splints for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide services and treatment to prevent further limitations in range of motion (ROM) for two residents with existing ROM limitations. Both residents had a history of stroke with hemiplegia affecting the non-dominant left side and were assessed as having limitations in ROM on one side of both upper and lower extremities. Care plans indicated the need for assistance with activities of daily living (ADLs), and occupational therapy discharge summaries recommended the use of hand or forearm splints. Physician orders specified that splints were to be applied continuously or daily, with regular checks for skin integrity. Despite these orders and care plan interventions, multiple observations revealed that both residents were not wearing their prescribed splints during various times of the day, both while in bed and seated in their wheelchairs. In one case, the splint was observed on the nightstand rather than on the resident. The Director of Nursing confirmed that the splints were to be applied as ordered for both residents, indicating that the facility did not follow physician orders and therapy recommendations to maintain or improve ROM.