Failure to Provide Ordered Range of Motion Devices Due to Documentation and Training Issues
Penalty
Summary
A deficiency was identified when a resident with a history of hemiplegia and hemiparesis following a stroke, affecting the left non-dominant side, did not receive appropriate treatment and services to maintain or improve range of motion (ROM) as required by facility policy and physician orders. The resident's care plan and physician orders specified the use of a left elbow extension splint and a left hand roll splint to be applied for six hours daily, with nursing staff responsible for skin checks before and after application to reduce joint stiffness and contractures. However, observations on multiple days revealed that the splints were not applied, and the equipment was found unused at the resident's bedside. Further investigation through interviews and record reviews showed that the resident had not had the splints applied for about a week and believed that nursing staff did not know how to apply the equipment. The electronic treatment administration record did not reflect the orders for the splints, and the assistant director of nursing confirmed that the orders were inaccurately placed, making them inaccessible to nursing staff during treatment administration. Additionally, there was no confirmation that nursing staff had received training on how to apply the splints. These findings were confirmed with the director of nursing.