Failure to Provide and Document Restorative Devices for Resident with Contractures
Penalty
Summary
The facility failed to provide appropriate restorative care for a resident with severely contracted hands, resulting in a deficiency related to the maintenance and improvement of range of motion (ROM). Staff did not follow facility policy and procedures, as they were unaware of the resident's required restorative devices, such as hand splints or palm protectors. The resident's name was missing from both the splints/brace/prosthetic log and the nursing rehab assistance log, and the comprehensive care plan did not include any mention of splints, braces, or prosthetics. During observation, the resident was found not using splints despite severe hand contractures and reported being unable to move her fingers. The resident also indicated she had lost her hand splint and was considering ordering another one. Interviews with staff, including the assigned LPN, DON, and restorative nurse, revealed a lack of awareness regarding the resident's need for restorative devices. The restorative nurse stated that such information should be included in the electronic medical record (EMR) tasks, but upon review, the required device was not listed. The care plan was only updated to include the splint program after the surveyor's inquiry, nearly two years after the resident's admission. Facility policy requires assessment and documentation of restorative needs upon admission, with services reflected in individualized care plans and electronic logs, but these steps were not followed for this resident.