Failure to Remove Arm Positioning Device After Procedure
Penalty
Summary
A deficiency occurred when a resident's right wrist remained secured in an arm positioning device following a mid-line catheter insertion. The device, intended to stabilize the arm during the procedure, was not removed after completion, leaving the resident unable to move their arm freely. Multiple staff members, including CNAs and LNs, became aware of the device during shift changes and routine care, but the device remained in place for an extended period. The use of the device was not documented, nor was its continued presence reported to the licensed nurse on duty by the nurse who performed the procedure. The resident involved had a medical history that included a recent fall, abnormal gait, and impaired mobility, making them particularly vulnerable to hazards. Staff interviews revealed that the arm positioning device was noticed by several caregivers during their shifts, but there was confusion and lack of clear communication regarding its removal. One CNA removed the device temporarily to provide care but replaced it afterward, while a licensed nurse was informed about the device but did not remove it, instead passing the information to the next shift. Another nurse instructed that the device should be removed, but it remained in place until further inquiry. Facility policy required that hazardous equipment and devices be identified and addressed to ensure resident safety. The failure to remove the arm positioning device, document its use, and communicate its status to the appropriate staff resulted in the resident's arm being unnecessarily restrained and secured to the bedframe. This situation had the potential to cause discomfort and emotional distress to the resident, as confirmed by the administrator and clinical nurse officer during interviews.