Failure to Apply Physician-Ordered Splint for Contracture Management
Penalty
Summary
A deficiency was identified when a resident with diagnoses of heart failure, diabetes, and dysphagia did not receive a physician-ordered right upper extremity elbow extension splint and resting hand splint. The physician's order, in place since February 2023, specified that the splints should be applied in the morning and removed in the evening, with skin checks before and after use. The resident's care plan also included interventions for contracture management, including participation in restorative programs and use of a right wrist support brace. During the survey, the resident was observed without any splints and reported that he used to wear a device on his hand but it was taken away without explanation. The unit manager confirmed that the splint had not been applied, and a review of the Treatment Administration Record and Medication Administration Record showed no evidence of the splint being used as ordered during the review period. The occupational therapist also confirmed the resident's need for the splint to manage muscle tone. These findings indicate that the facility failed to implement the physician's order for contracture prevention devices.