Failure to Apply Physician-Ordered Splints for Residents with Contractures
Penalty
Summary
Facility staff failed to ensure that residents with physician orders for splints or positioning devices received care as directed. One resident with bilateral upper extremity contractures was observed multiple times without the ordered right arm splint, which was to be worn daily for six hours according to the Treatment Administration Record. There was no documentation in the medical record explaining why the splint was not applied, and the splint was not observed in the resident's room during any of the surveyor's visits. The DON confirmed the existence of the order and stated that staff are expected to follow physician instructions. Another resident, who had an order to wear a rolled cloth on the left hand for ten hours daily after morning care and a care plan intervention for splint use to prevent contractures, was also observed on several occasions without the required splint. Staff confirmed that the resident should have been wearing the splint at the time of observation. The DON was notified of these findings, which demonstrated a failure to provide care as ordered to maintain or improve range of motion and prevent further contractures.