Failure to Provide Ordered Palm Guard to Maintain Resident ROM
Penalty
Summary
A resident with severe cognitive impairment, dependent for all ADLs, was admitted with a physician’s order for a left palm guard to be applied in the morning with AM care and removed with PM care, with no stop date. The care plan also directed staff to apply a palm guard to the resident’s left hand at 10:00 AM for up to six hours daily as tolerated after morning care, as part of interventions to maintain skin integrity and prevent contractures. An annual MDS documented that the resident required substantially maximal assistance with all ADLs. On multiple observations over several days, the resident was repeatedly seen without the ordered left-hand palm guard during morning and afternoon timeframes when it should have been in place. Two CNAs interviewed stated they had never applied and had not seen the palm guard on the resident’s left hand. The Quality Manager confirmed that the resident did not have a left palm guard, and the Director of Rehab later confirmed that the left hand palm guard order, originally entered as a standard order with no stop date, had been stopped by mistake about one month after admission. The facility lacked evidence that the palm device was applied to the resident’s left palm as ordered and care planned.
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