Failure to Implement and Care Plan Ordered Shoulder Subluxation Splint
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility as ordered. Facility policy required that splints be issued or fabricated with a provider's order, that a therapist evaluate the patient for need, fit, and issuance, and that the splint schedule be communicated to the multidisciplinary team and documented in the care plan. The resident in question had diagnoses including high blood pressure, stroke, and hemiplegia, and had a physician's order to wear a left shoulder subluxation sling on with morning care and off with evening care, as tolerated twice a day. However, the resident's current care plan did not include management and treatment of the left shoulder subluxation splint. During observations, the resident was seen in a wheelchair without the ordered left shoulder subluxation splint in place. The resident reported that staff never put the splint on, was unsure of its location, and stated that the splint reduced pain. An LPN confirmed that the splint was not in place as ordered. Later observation showed the resident still in the wheelchair without the splint, and the resident indicated that staff could not find it. The DON confirmed that the facility failed to ensure the resident with limited mobility received the appropriate services, equipment, and assistance to maintain or improve mobility.
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