Failure to Ensure Physician-Ordered Palm Protector Applied for Contracture Management
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple complex diagnoses, including ataxia, stiff-man syndrome, dementia, mood disorder, weakness, repeated falls, malignant neoplasm of the brain, and epilepsy, was not provided with a palm protector as ordered by the physician for contracture management of his right hand. Observations on two consecutive days revealed the resident's right hand was tightly curled with fingers digging into the palm, and no palm protector was in place. The resident stated he only wore the device when working, and a newly hired CNA reported never seeing the resident wear the palm protector. Documentation in the electronic medical record indicated the device was applied, but direct observation contradicted this. Further interviews with staff revealed that while there were instructions and documentation processes in place for the application of the palm protector, there were no scheduled verification checks after transfers or meals to ensure the device was reapplied as required. The facility was unable to provide a policy regarding following physician's orders during the survey. These actions and inactions led to the failure to ensure the resident consistently received the prescribed contracture management intervention.