Failure to Provide Prescribed Orthotic Devices for Residents with Limited Mobility
Penalty
Summary
The facility failed to ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve their mobility, as required by physician orders and facility policy. Three residents with diagnoses including stroke, high blood pressure, and hemiplegia had specific orders for the use of splints, braces, and guards to prevent contractures, maintain joint alignment, and support functional use of extremities. Documentation reviews revealed multiple instances where these devices were not applied as ordered, with records showing days marked as 'No', 'Not Applicable', or left blank, indicating the devices were not used or there was no evidence of their application. For one resident, the ankle brace was not applied on 14 out of 29 days, the palm guard on 6 days, the elbow splint on 14 days, and the hand brace on 15 days. Another resident did not have a hand splint applied on 18 out of 29 days, and during an interview, the resident stated they did not know the location of the splint. A third resident's hand splint was not applied on 14 out of 29 days, with documentation similarly marked as 'Not Applicable' or left blank. Interviews with residents and staff confirmed the lack of consistent application of prescribed orthotic devices. The Assistant Director of Nursing acknowledged that the facility failed to provide the necessary services, equipment, and assistance to maintain or improve mobility for all three residents reviewed. These findings were based on facility policy review, clinical record review, observations, and interviews.