Failure to Implement Physician-Ordered Device for Range of Motion
Penalty
Summary
A deficiency was identified when a resident with limited motion on her left side, including her left hand, did not receive a physician-ordered carrot device in her left hand after passive range of motion (PROM) exercises. Clinical record review confirmed an active order for PROM to the resident's left upper extremity and placement of the carrot device following the exercises. Observations on two separate dates showed the resident did not have the carrot device in place, despite documentation indicating PROM was completed. The resident reported that staff had not been placing anything in her left hand for about a week. The Nursing Home Administrator confirmed that the order for the carrot device was not carried through in the clinical record for nurse aides to implement.