A resident with stroke-related R-sided hemiparesis and a hand contracture was ordered to wear a resting hand splint on the R hand at all times except for hand washing and skin checks. Surveyors observed the resident multiple times without the splint, and the device was found stored in the room rather than in use. The resident said he did not think he had worn it for some time, CNA staff said they usually applied it but did not document it, and the EMAR/progress notes lacked documentation of application or refusal.
Two residents with neurological impairments and contractures did not consistently receive prescribed cervical collars and a mechanical back/cervical splint during bedrest and meals. One resident, ordered to wear a soft cervical collar in bed and for all meals for neck contracture management, was repeatedly observed without the collar, which was found on the bedside stand, and her care plan and CNA Kardex lacked instructions for its use or refusal despite documentation that she preferred wearing it. Staff gave conflicting accounts about whether the collar was still in use, and there was no documentation of refusals as required by facility policy. Another resident, ordered to wear a cervical brace during all meals, was repeatedly observed with her head leaning to one side, without the brace, and not eating, while CNAs reported the brace’s Velcro failed and her head slipped out despite repeated attempts to reposition and reapply it. Therapy and restorative staff acknowledged ongoing issues with the brace, missed reassessment, and lack of reported concerns, contrary to facility policy requiring regular assessment and reporting of problems with assistive devices.
Restorative Services Not Initiated After Rehab Discharge: A resident with COPD and healing pelvic fractures was cleared to WBAT with a walker and was to be discharged to restorative and nursing staff, but no restorative plan was initiated. Nursing notes lacked any reference to therapy or restorative care, and staff interviews confirmed the order was missed and no restorative services had been set up. The DON later cited therapy refusal, but the screen tool did not document the resident's refusal.
A resident with a history of stroke, severe protein malnutrition, seizures, pressure ulcer, and a documented right lower extremity contracture was admitted with limited ROM in both legs and was dependent for ADLs. PT was ordered to address decreased strength, impaired balance, and functional mobility, including a goal for use of a knee orthotic to inhibit abnormal positioning. However, the initial PT evaluation did not document lower extremity strength, degree of contracture, or specific functional limitations, and subsequent PT notes showed only assisted ROM and gentle stretching, with the resident unable to perform ROM independently. The right knee orthotic was briefly trialed but removed after short periods due to pain, and there was no further documented use or clinical rationale for discontinuation, despite recertified plans that continued to reference possible orthotic management. Staff interviews confirmed lack of clear documentation regarding the orthotic’s ordering, fitting, and discontinuation, and the restorative nurse reported the right knee contracture remained unchanged at the time of review.
A resident with a right femur fracture, prior lower-extremity fractures, difficulty walking, and dependence on staff for mobility and transfers was observed being moved from a wheelchair to bed with a gait belt and slide board. Therapy had recommended slide board transfers with two people and placement toward the resident's good leg, but the EMR had no physician order or comprehensive person-centered care plan for slide board use, and the DON confirmed none was in place.
A resident with traumatic brain injury, dementia, and bilateral upper extremity contractures had physician orders and a care plan for daytime use of bilateral palm protectors/hand orthoses, but surveyors repeatedly observed the resident without one or both splints in place. The MAR showed no refusals, and the resident was documented as severely impaired in decision making and needing assistance with self-care. Despite a facility policy assigning nurses responsibility for consistent use and monitoring of orthotic devices, staff did not ensure both hand splints were consistently applied as ordered.
Failure to apply ordered ROM devices: two residents were observed without a left-hand splint or palm protector in place despite care plans and physician orders directing their use. One resident with hemiplegia and impaired ROM said he was unsure when to wear the splint, and the DON stated there was no clear schedule. Another resident with Alzheimer's disease and severe cognitive impairment was repeatedly observed in bed without the ordered palm protector on the left hand.
A resident with left hand contracture, mild cognitive impairment, and significant ADL assistance needs was ordered to wear a left palm protector daily to help maintain ROM and skin integrity. During multiple observations, the resident was found in bed with the contracted hand uncovered and without the ordered padding or brace in place; the palmgrip was later found soiled in a bedside drawer, and an LPN stated it should have been in place.
A resident with hemiplegia and impaired ROM was observed wearing a left-hand splint during the day even though the MD order directed staff to apply the brace at bedtime and remove it in the morning. The DON said the family may have put the splint on the resident, while the facility policy stated nursing is responsible for applying and removing the splint per schedule.
Failure to implement ordered hand splints for a resident with RA and bilateral hand contractures. OT notes said the splints fit properly, were in good functional order, and should be worn at night, but there was no nursing chart order or documentation that management was aware of the order. The DON stated she should have entered the order for the resident’s bilateral hand splints.
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