Failure to Provide Contracture Management for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with a history of nontraumatic intracranial hemorrhage and tracheostomy status, who was admitted to the facility with limited range of motion, did not receive appropriate treatment and services to prevent further decrease in range of motion. Physician orders specified that a clean rolled gauze should be placed in the resident's right hand for passive stretch and a carrot orthosis should be used on the left hand for contracture management. The resident's care plan also indicated the use of resting hand splints during the daytime for 6-8 hours. During an observation, it was noted that the rolled gauze was not in place on the resident's right hand as ordered. When questioned, a nurse aide stated that the gauze was for wound care and that the wound care nurse was responsible for placing it. However, the Director of Rehabilitation clarified that the gauze was intended for contracture management, not wound care. This miscommunication and lack of proper implementation of the physician's orders resulted in the resident not receiving the prescribed intervention to prevent further loss of range of motion.
Plan Of Correction
1. Resident R12 had gauze applied per physician orders. 2. Other Residents with splints were checked for proper appliance per physician orders. 3. Random audits will be conducted by DON or designee weekly x4 and monthly x3 to ensure proper application of splints/devices per orders. 4. Results of the audits will be reported to the QAPI committee.