Improper Application and Monitoring of AFO for Resident With Limited Mobility
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure proper application and monitoring of an ankle foot orthosis (AFO) as ordered by the physician for a resident with significant neurological and medical conditions. The resident had a history of traumatic brain injury, seizures, hydrocephalus, type 2 DM, and difficulty swallowing, and the H&P documented that the resident lacked capacity to understand and make decisions. A physician order dated 6/9/2025 directed that bilateral AFOs be placed on the resident’s lower extremities five times per week for 4–6 hours as tolerated, with skin checks. During an observation in the resident’s room, the resident was found lying in bed with an AFO on the right foot and ankle that was rotated to the side and not providing the intended support. During a concurrent observation and interview at the bedside, the Director of Rehabilitation confirmed that the right AFO was not applied properly and stated that the brace should be supporting the right foot and ankle to prevent further foot drop. Later, the RNA reported that he had applied the right AFO that morning in accordance with the physician’s order but was unaware that it was not correctly positioned, and acknowledged that the AFO should remain in the correct position on the foot and ankle. The DON also stated that the AFO should remain correctly positioned at all times and that staff should monitor both the placement of the AFO and the resident’s skin condition while it is in place. Facility policies on assistive devices and on resident mobility and ROM required that staff be trained and competent in the use of devices and that residents with limited mobility receive appropriate services and equipment based on professional standards of practice, but the observed improper application of the AFO demonstrated noncompliance with these requirements.
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