Failure to Ensure Use of Hand Rolls for Resident with Limited ROM
Penalty
Summary
A resident with diagnoses including cerebral palsy and gastrostomy status had physician orders and a care plan intervention for bilateral hand rolls to be worn when out of bed, in order to address impaired mobility and prevent contractures. Despite these orders, observations on two consecutive days showed the resident sitting in a wheelchair without the required hand rolls in place. Documentation indicated that a nurse aide had applied the hand rolls earlier in the day, but they were not present during subsequent observations. Interviews with facility staff revealed uncertainty regarding the whereabouts of the hand rolls, with the LPN unable to locate them in the resident's room. The DON later confirmed that the nurse aide had removed the hand rolls for care and forgot to reapply them, and the hand rolls were later found in the resident's drawer by therapy staff. The facility's expectation, as stated by the Nursing Home Administrator, was that the hand rolls should be applied according to physician orders.