Failure to Implement Therapy Recommendations for Hand Splints in Residents with Contractures
Penalty
Summary
The facility failed to implement occupational therapy (OT) recommendations for the use of hand splints for three residents with contractures. For one resident with cerebral palsy and quadriplegia, the OT discharge summary recommended use of a left hand splint for three hours daily to prevent worsening contractures. However, there were no corresponding orders or care plan updates in the electronic medical record (EMR), and the resident reported that after therapy services ended, no one assisted with applying the splint, which was observed unused in the room. Another resident with a right hand contracture had OT recommendations for continued use of a right hand splint, but the care plan did not address this intervention, and no orders or treatments were found in the EMR. Observations showed the resident's hand contracted and the splint not in use, with staff interviews confirming a lack of follow-through on therapy recommendations after discharge from rehabilitation services. The Director of Nursing (DON) and Rehabilitation Director acknowledged communication failures between nursing and therapy regarding the implementation of splinting orders. A third resident with a right hand contracture and severe cognitive impairment had a physician order and care plan interventions for daily splinting, but observations revealed the resident was not wearing a splint, and staff were unaware of the need. The occupational therapist confirmed the resident should have a palm guard, but it was not found in the room, and staff reported using a towel instead. Interviews with facility leadership confirmed gaps in documentation, communication, and implementation of splinting interventions as recommended by therapy.