Failure to Provide Appropriate Mobility and Skin Integrity Interventions for Residents with Limited Mobility
Penalty
Summary
The facility failed to ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. For one resident with diagnoses including high blood pressure, hyperlipidemia, and Alzheimer's Disease, there was no documented assessment of a right hand brace provided after an orthopedic appointment, nor was the appearance of the hand upon return recorded. The resident subsequently experienced skin irritation and a skin tear below the thumb, with the brace found to be too small and causing damage. The facility did not have a policy for assistive devices or splints, and staff confirmed the lack of documentation and assessment regarding the brace. Another resident with osteomyelitis of the vertebra, depression, and atrial fibrillation had a physician order for a thoraco-lumbar sacral orthosis (TLSO) brace, but the order did not specify directions for use or interventions for monitoring skin integrity under the brace. The resident's care plan also failed to include interventions for monitoring skin integrity. Staff interviews confirmed these omissions, and the Director of Nursing acknowledged the failure to provide appropriate services and documentation for both residents.