Failure to Address Ongoing Refusal of Hand Orthotic and ROM Needs
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a right-hand contracture received appropriate treatment and services to maintain or improve range of motion (ROM) and prevent further decline. The resident, who had a history of stroke with aphasia and a right-hand contracture, was discharged from OT with a right grip orthotic/resting hand splint to be worn during daylight hours as tolerated, with an excellent prognosis to maintain function with consistent staff support. The care plan directed staff to apply the right-hand grip splint for eight hours as tolerated. Subsequent documentation showed the resident frequently refused to wear the orthotic, with TAR entries indicating refusals on numerous days over several consecutive months. A physician communication in early October documented that CNAs reported the resident refused to wear the brace daily and exhibited high pain when staff attempted to place fingers into his contracted hand, and a re-evaluation for therapy options was recommended. Despite ongoing refusals documented in the TAR and monthly summaries noting the resident’s contractures and refusal to wear the orthotic, there was no further documentation after early October that the physician, therapy department, or the resident’s representative were notified of these continued refusals. The resident was not referred back to therapy after his initial OT discharge in July, even though the OT and DOR confirmed no subsequent therapy referrals. A restorative program for PROM to the right hand was initiated in January, with care plan directions to perform PROM and approach the resident by asking to hold his hand, and restorative evaluations in February and March documented participation in the PROM program. However, the Restorative Coordinator stated she was unaware of how long the resident had been unable to open his right hand and that he was referred to the restorative program only in January due to tightness. The DON stated that the expectation when a resident continued to refuse a splint would be to refer to therapy, notify the representative, provide education, and notify the physician, but she did not recall being informed of the ongoing refusals. The lack of timely and consistent communication and follow-through with the interdisciplinary team regarding the resident’s persistent refusals to wear the orthotic and his increasing hand tightness led to the deficiency.
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