Failure to Implement Therapy-Recommended Hand Splint for Resident with Contracture
Penalty
Summary
The facility failed to follow occupational therapy recommendations for a resident with a left-hand contracture, specifically the application of a soft hand splint for 4-6 hours daily as outlined in the OT discharge summary. Multiple observations over several days revealed the resident's left hand remained contracted, with the prescribed splint consistently found unused on the nightstand. The resident confirmed that staff had not been applying the splint for an extended period, though he could not specify the duration. Interviews with facility staff, including the Rehabilitation Director, Restorative Nurse, Occupational Therapist, DON, and Administrator, revealed a breakdown in communication and documentation regarding the transition from therapy to restorative nursing services. The Restorative Nurse reported not receiving a restorative services request for the resident, and the DON was unaware of any formal process or documentation for relaying restorative nursing needs. The Administrator acknowledged that therapy recommendations should be followed until reassessment, but cited recent staff changes as a possible reason for the lapse in care.