Failure to Apply Prescribed Hand Roll for Resident with Contracture
Penalty
Summary
A resident with a diagnosis of left-hand contracture and dementia was admitted to the facility and required total assistance with all activities of daily living due to limited mobility and cognitive impairment. The resident's care plan and physician order specified the use of a hand roll in the left hand each morning, to be removed at night, as a preventative measure against worsening contracture. Multiple observations over two days revealed that the resident was seated in a Geri-chair with the left wrist bent downward and without a hand roll, brace, or splint in place as ordered. Interviews with facility staff, including the Infection Preventionist, Director of Nursing, and Director of Rehabilitation, confirmed that the hand roll should have been applied according to the physician's order. The facility was unable to provide a policy or procedure for following physician orders. The failure to apply the prescribed hand roll as ordered constituted a deficiency in care for the resident with a left-hand contracture.