F0688

D

Failure to Implement Contracture Management and Positioning Interventions

Burr Ridge, Illinois Survey Completed on 12-31-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide and apply recommended devices for contracture management and positioning to residents with known contractures, as outlined in their care plans and therapy recommendations. One resident, a 78-year-old under hospice care with hemiplegia and a left-hand contracture, had a care plan intervention specifying application of a left-hand splint on for 12 hours and off for 12 hours. A therapy form documented that a resting hand splint had been provided but was missing. Across multiple observations over several days, the resident was repeatedly seen in bed with the left arm and hand contracted and the hand tightly clenched, with fingers digging into the palm. There was no resting hand splint, palm protector, carrot splint, or rolled towel in use or present in the room. A CNA reported that the resident used to have a carrot splint and was using only a thin dressing on the palm to protect the skin from fingernails.

Another resident, a 73-year-old with dementia, functional quadriplegia, and contractures of the upper and lower extremities, had therapy documentation indicating contractures and a need for cuing to relax limbs and pillow placement to increase comfort and decrease skin breakdown. This resident’s care plan identified contracture, quadriplegia, and chronic pain syndrome, with interventions including non-pharmacological pain mechanisms such as comfortable positioning. During multiple observations over several days, the resident was seen resting in bed with contracted hands, wrists, and bilateral lower extremities. The lower extremities were contracted and adducted, with the skin of the legs touching and rubbing together, and there was no wedge pillow or other pillow placed between the knees, despite the documented need for such positioning support.