Failure to Apply Physician-Ordered LAFO for Resident with Limited Mobility
Penalty
Summary
A resident with diagnoses including hemiplegia, hemiparesis, hypertension, and sleep apnea was admitted to the facility and had a physician order for a left ankle-foot orthosis (LAFO) to be applied in the morning and removed with evening care, with skin checks before and after application. The resident's care plan also included this intervention to address self-care deficits related to impaired mobility. However, documentation in the clinical record did not provide evidence that the LAFO was applied as ordered. Multiple observations over several days showed the resident sitting in a wheelchair without the LAFO on the left foot/leg during both morning and afternoon hours. During an interview, the Regional Nurse Consultant confirmed that the resident did not have the LAFO in place as per the physician's orders and acknowledged that it should have been applied. This failure to follow physician orders and provide the prescribed treatment and services resulted in a deficiency related to maintaining or improving the resident's range of motion.