Failure to Consistently Implement Physician-Ordered Hand Splint for ROM
Penalty
Summary
Facility staff failed to implement physician-ordered interventions for a resident with limited range of motion (ROM) in her hands. The resident had an active physician's order and a care plan directing staff to ensure she wore a left palm guard with digit separators for four hours in the morning and four hours in the evening, with skin checks every two hours. Multiple observations over several days showed the resident was not wearing the splint as ordered, and her hands were contracted, with her using her knuckles or fists to grasp objects. Documentation revealed inconsistent application and documentation of the splint, with some staff unaware of the correct schedule for its use. Interviews with nurse aides and the resident's husband confirmed inconsistent use of the splint, with staff unsure of the schedule and some unaware of the intervention altogether. The care instructions available to staff were vague, and documentation of the intervention was incomplete, with no staff initialing the application of the splint on certain shifts. The deficiency was discussed with facility leadership, confirming the lack of consistent implementation of the physician's order and care plan for contracture prevention.