F0686

G

Failure to Manage Hand Contracture and Nail Care Resulting in Palm Wound and Infection

Coeur D'alene, Idaho Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide consistent and necessary care to prevent a pressure-type ulcer and infection in a resident with a right-hand contracture following a stroke. The resident had aphasia and a care plan that directed staff to trim and file his nails weekly and as needed, and to apply a right-hand grip splint during the day as tolerated. Occupational therapy initially evaluated the resident in July 2025 for feeding and right-hand contracture, discharged him on 7/15/25, and provided an orthotic splint to keep his fingers in a resting position. After this discharge, there were no further therapy referrals despite ongoing issues with the contracture.

The resident frequently refused to wear the hand grip orthotic, with refusals documented on the TAR for most days over several consecutive months. A communication note to the physician on 10/6/25 documented that CNAs reported the resident refused to wear his brace and had high levels of pain when staff attempted to place their fingers into his contracted hand, and a re-evaluation for therapy options was recommended. However, there was no subsequent documentation that the physician, therapy department, or the resident’s representative were notified of the continued refusals after that date, and no documentation of further interventions or treatment for pain related to the right-hand contracture. Monthly summaries in early 2026 noted the contracture and refusal to wear the orthotic, but did not reflect additional action.

By March 2026, the resident’s contracted hand had become swollen and painful, with nails digging into the palm and white/yellow drainage noted. A communication note on 3/12/26 recorded provider orders to trim nails, apply triple antibiotic ointment, and cover the wounds, along with a handwritten note that staff were unable to open the right hand to trim nails or apply ointment due to contraction and swelling. A provider note on 3/13/26 documented that the nails were embedded into the palm causing skin infection, and that after soaking the hand, the nails were trimmed and antibiotic cream placed in the palm. Staff interviews revealed that restorative staff could barely open the hand and had not seen the palm or fingernails, and that an LPN was aware of the resident’s refusal to wear the splint but did not document family education. The DON could not find documentation that the resident’s fingernails were trimmed or that refusals to nail care were recorded, and the nurse practitioner stated the wound was due to the fingernails digging into the palm. The National Library of Medicine reference cited in the report noted that spastic fingers pressing into the palm with overgrown nails can cause skin breakdown and atypical pressure ulceration.