Failure to Provide and Document Required Range of Motion Interventions
Penalty
Summary
A resident with anoxic brain damage and contractures of the bilateral lower extremities was not provided with the appropriate treatment and equipment to prevent further decline in range of motion. The resident's care plan required the use of a left knee splint, a lower extremity positioning device, and heel boots. However, during observations and interviews, it was found that the left knee splint had been missing for several weeks, and staff were unable to locate it. The positioning cushion was also not immediately available, and only one heel boot could be found. Staff members were unsure about the correct application of the devices and whether two heel boots were required. Additionally, the shift report sheet did not consistently list all required equipment, and some staff were unfamiliar with the resident's care needs due to infrequent assignment. Documentation in the electronic health record indicated that the left knee splint was applied on multiple dates, even though it was missing during that time. The resident care coordinator confirmed that the splint was not available and that staff should not have documented its application. Furthermore, the lower extremity positioning device and heel boots were not included in the electronic documentation system for staff to sign off, leading to incomplete and inaccurate records of care. These failures resulted in the resident not receiving the necessary interventions to maintain or improve range of motion, as outlined in the care plan.