Failure to Apply Prescribed ROM Devices for Resident with Contractures
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and hemiplegia was not provided with prescribed range of motion (ROM) devices, specifically a right knee and elbow brace, as outlined in their care plan. The resident, who was dependent on staff for all activities of daily living and had contractures in both upper and lower extremities, was observed multiple times without the required devices in place. The care plan and Kardex specified that the right knee and elbow braces should be worn at all times except during skin checks and hygiene care, but these instructions were not consistently visible or communicated to the staff responsible for the resident's care. Interviews with multiple Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) revealed that they were unaware of the need to apply the braces and had not seen or applied them during their care of the resident. The CNAs also reported that the devices were not visible in their electronic medical record task lists, and they were unsure how to access such instructions. The charge nurse and other supervisory staff were also unaware that the CNAs could not view or implement the care plan instructions regarding the devices. Further investigation showed that the devices were found unused in the resident's closet, and there was no documentation in the CNA task records indicating that the braces had been applied over a period of several months. The Rehabilitation Director confirmed that the devices had been issued and were to be applied at all times except for care, but audits to ensure compliance had not been conducted recently. The Director of Nursing and Assistant Director of Nursing stated that staff were expected to follow the care plan, but they were not aware that the devices were not being used as intended.