Failure to Consistently Apply Splints as Ordered for a Dependent Resident
Penalty
Summary
The facility failed to consistently implement and provide splints as ordered for a resident with cerebral palsy, chronic respiratory failure, and quadriplegia, who was dependent on staff for all activities of daily living and unable to communicate or make decisions. The resident's care plan required the application of splints to both hands and elbows, alternating days on each side, for up to four hours daily as tolerated. Observations on multiple occasions showed the resident without splints in place, both in bed and in a wheelchair, despite documentation in the electronic health record indicating that splints had been applied. Interviews with staff revealed inconsistencies in the application and documentation of splint use. Restorative nursing staff stated they applied the splints and signed for them, but observations did not corroborate this. Paper documentation showed irregularities, including unclear or altered times for splint removal and instances where nursing staff removed the splints without clear documentation of reapplication. These actions and inactions resulted in the resident not receiving the prescribed splint therapy as outlined in their care plan.