Failure to Monitor and Document Palm Protector Use Leads to Severe Hand Injury
Penalty
Summary
A resident with severe cognitive impairment, hemiplegia, and multiple comorbidities was admitted to the facility and was dependent on staff for all activities of daily living. The resident had a history of contractures and was at risk for skin breakdown, as documented in his care plan. Despite these risks, a palm protector device was placed on his contracted left hand without a physician's order, care plan update, or proper monitoring. The device remained on the resident's hand for approximately seven days, during which time staff failed to remove the device to assess the underlying skin integrity, as required by professional standards and facility policy. Multiple staff members, including nurses and CNAs, observed the device on the resident's hand but did not remove it or adequately assess the skin beneath. Some staff were unaware of who placed the device or the need for monitoring, and there was no documentation of the device in the resident's treatment record. The therapy department did not recommend the device, and the occupational therapist could not find any documentation supporting its use for this resident. Nursing staff performed routine skin assessments but did not remove the device, and changes in the resident's hand condition, such as swelling, redness, and the presence of a wound, were either not noticed or not reported in a timely manner. The deficiency became evident when the resident was observed with a swollen, red, and painful left hand, with a deep, foul-smelling wound in the thenar web space. The device was found embedded in the wound, and the resident was subsequently transferred to an acute care hospital, where he was diagnosed with cellulitis, leukocytosis, and a deep, chronic-appearing pressure wound. Interviews with staff revealed a lack of training and awareness regarding the use and monitoring of assistive devices, as well as failures in communication and documentation. The facility's failure to ensure proper assessment, monitoring, and documentation of the palm protector device directly led to the resident developing a serious, avoidable injury.
Removal Plan
- Audit all residents with palm protectors and splints to ensure orders and care plans are in place
- Educate staff
- Conduct skin sweep
- Monitor hand roll/splint placement, removal, and skin integrity
- Train therapy department on donning and doffing of braces, splints, and palm guards
- Train nursing and therapy staff on assistive devices, including obtaining doctor's orders prior to placement, notifying nursing department of order and device placement, and monitoring as indicated
- Train nursing staff, including CNAs, nurses, and medication aides, on notification of changes of condition, including any change to a resident's skin, and reporting the change of condition to the nurse
- Educate Treatment Nurse A on skin assessments and removing assistive devices to assess skin integrity
- Implement orders, care plans, and monitoring on treatment record for residents utilizing palm protectors and splints
- Assess all residents' skin for suspicious areas or marks
- Complete skin assessments for all residents
- Train therapy and nursing staff on assistive device procedures, including obtaining an order, following the order including time restrictions for the device, and monitoring the use of the device