Failure to Ensure Ordered Orthopedic Devices and ROM Supports Were Used as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents with limited range of motion received prescribed orthopedic devices and related services to maintain or improve function. For one male resident with severe cognitive impairment and a history of traumatic brain compression and left hand pain, the MD ordered a left hand splint to be worn at all times. Surveyors observed this resident in bed on two occasions without the left hand splint in place, once with the splint found on the dresser. His care plan addressed risk for skin breakdown and a right hand splint, but contained no care plan focus or interventions for the ordered left hand splint. Another male resident with severe cognitive issues, chronic diastolic CHF, morbid obesity, and COPD had an MD order to wrap his right knee with an Ace bandage during the day and remove it at bedtime for arthritis pain. His care plan addressed potential for pain and risk for injury from decreased ADLs, but did not include the Ace bandage order or related interventions. During observation, this resident was found in bed without the Ace bandage on his right knee, despite the standing order. The ordering MD later clarified that the Ace bandage was to be applied as needed and emphasized the importance of following orders or notifying him if there were issues. A younger female resident with bipolar disorder, fractures of the right femur and right humerus, and a left hand contracture had an MD order for a left wrist splint to be worn at all times. Her care plan documented impaired physical mobility with a left hand contracture and noted a splint in place, with an intervention to consult PT to evaluate ROM and motor movements. However, during observation she was in bed without the left wrist splint on. She reported that when she first came to the facility she had a contracture on her right hand and received therapy, and that she puts her brace on herself. The interim DON and Administrator both stated that if residents had orders for splints or an Ace bandage, they should have been wearing them, and that nurses were responsible for ensuring orders were followed and communicating refusals or issues with the MD. The facility’s failure to ensure these prescribed devices were in use as ordered, and to incorporate the orders into the residents’ care plans, was cited as placing residents at risk of impaired skin integrity, further decline, and decreased quality of life and quality of care.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.