Failure to Implement and Document Contracture Interventions
Penalty
Summary
Facility staff failed to implement interventions to prevent the worsening of contractures for a resident with bilateral contractures in both hands and feet. The resident was repeatedly observed lying in bed with contracted hands and feet, and no contracture-related devices were in use during these observations. Interviews with nursing and therapy staff confirmed awareness of the contractures, but there was no evidence in the clinical record or therapy notes that the contractures had been assessed or that interventions had been implemented. Nursing staff stated that interventions, such as floating heels and placing items in the resident's hands, were used as tolerated, but there was no documentation to support these claims or to indicate the resident's tolerance or refusal. Further review revealed that therapy staff had not assessed or treated the contractures, and previous therapy records were unavailable due to changes in therapy providers. The facility's policy indicated that range of motion exercises were performed daily with bathing and were not documented. However, there was no evidence that these exercises or any other interventions were being carried out or documented for the resident's contractures, leading to a failure to address the resident's needs for maintaining or improving range of motion.