Failure to Implement Ordered Palm Guard for Resident with Limited ROM
Penalty
Summary
A resident with a history of left-sided weakness and paralysis due to a stroke, as well as cognitive impairment and dependence on staff for daily activities, was identified as having a loss of range of motion in the left upper extremity. The care plan included a physician's order for staff to apply a palm guard to the resident's left hand in the morning and remove it in the evening. However, during multiple observations over two days, the resident was found without the palm guard on the affected hand. The DON confirmed that the palm guard was to be in place as ordered by the physician. This failure to implement the ordered intervention resulted in the facility not providing appropriate care to maintain or improve the resident's range of motion.