Failure to Implement Ordered Elbow Splint for ROM Maintenance
Penalty
Summary
The facility failed to implement ordered interventions to maintain or improve range of motion for a resident with significant contractures and neurological impairment. The resident had diagnoses including anoxic brain damage, respiratory failure with hypoxia, persistent vegetative state, and contractures, and a Minimum Data Set assessment showed limitations in ROM in both upper and lower extremities on both sides. The care plan indicated the resident required assistance with ADLs such as personal hygiene, transferring, and bed mobility. An occupational therapy discharge summary specified that the resident should use orthotics to maintain ROM and skin integrity. A physician order dated January 13, 2026, directed staff to apply a Posey Soft elbow extension splint as tolerated and to alternate upper arm use during daytime hours. Observations on March 3 and March 4, 2026, showed the resident was not wearing the Posey Soft elbow extension splint during the observed time periods. Review of the clinical record revealed no documentation that the splint had been implemented as ordered. On March 4, 2026, the Director of OT documented that the resident had not been wearing the splint and that staff were unable to locate it. The Director of OT confirmed in an interview that the splint was supposed to be in use as ordered.
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