Failure to Implement and Document Range of Motion Interventions for Resident with Contracture
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to prevent further decline in her condition. The resident, a cognitively intact female with a history of stroke, hemiplegia, and diabetes, had a contracture in her left hand. Her care plan indicated the use of supportive devices such as splints as recommended by occupational therapy (OT), but there was no evidence that these interventions were consistently implemented. Documentation showed that the carrot splint was to be applied daily, yet there was no record of its application or refusal for a period of several days. Observations and interviews revealed that the resident's left hand was drawn up in a fist, and she was unable to open it. The splints intended for her use were found in her room but not in use, and the resident reported not having seen the splint in a while. Certified Nursing Assistants (CNAs) were unaware of the need to apply the splint or perform ROM exercises, and these tasks were not included on their task lists. The restorative aide also confirmed that the resident was not on her list for restorative care and had not documented any refusals or issues due to lack of access to the new electronic system. Further interviews with facility staff, including the MDS nurse, restorative aide, and Director of Rehabilitation (DOR), confirmed a lack of communication and documentation regarding the resident's restorative needs. The facility did not have a formal restorative program, and there was no specific restorative care plan in place for the resident. The failure to implement and document the prescribed interventions for the resident's contracture led to a deficiency in providing appropriate care to maintain or improve her range of motion.