The incident at Guardian Rehabilitation Hospital involved Resident 49, who was admitted with severe sepsis and septic shock and lacked the capacity to make medical decisions. Federal inspectors documented the splint misplacement during their January 30 visit to the facility on South Fairfax Avenue.
During an observation on January 28 at 10:38 a.m., inspectors watched RNA 1 take two knee splints from a closet and place them on Resident 49's legs. The nursing assistant put the left knee splint low on the resident's leg, with the knee portion of the splint positioned on the lower part of the leg rather than over the knee joint. The right knee splint was placed correctly.
RNA 1 indicated the treatment was complete and left the room.
Twenty-nine minutes later, Physical Therapist 1 observed the misplaced left knee splint and told inspectors it was "too low and should be put on higher." The therapist removed the splint and repositioned it correctly over the knee.
"Splints should be put on correctly because otherwise the splints were not serving its purpose, and the contracture could get worse," PT 1 told inspectors.
The physician had ordered nursing staff to put on and take off bilateral knee splints for four to six hours daily as tolerated to prevent further tightness and contractures. But physical therapy records revealed a critical safety issue with the duration.
Resident 49's PT discharge summary from December 11 showed the resident's maximum safe tolerance for wearing knee splints was three hours. The physical therapist had gradually increased the resident's wearing time from 30 minutes in November to three hours by December, monitoring for signs of skin breakdown, redness, swelling, discomfort or pain.
PT 1 told inspectors the nursing order should specify three hours maximum, not four to six hours. "Because Resident 49 was tolerating the knee splints for three hours with PT, Resident 49 should not wear the knee splint for more than three hours, because Resident 49 could have skin irritation, pain, skin breakdown, and soreness."
The Director of Nursing acknowledged that nursing assistants "need to place splints on residents correctly so that residents did not develop contractures and have limitations in range of motion."
Wrong Type of Exercises
Inspectors found similar problems with exercise therapy for Resident 54, a stroke patient with left-side weakness who was cognitively intact and capable of performing active range of motion exercises independently.
The resident had physician's orders for active range of motion exercises for both upper and lower extremities six times a week, along with supervised walking and stationary bike use. Active range of motion requires residents to move their own joints and muscles to maintain strength.
During an observation on January 28, inspectors watched RNA 1 walk with Resident 54 using a front-wheeled walker and supervise 10 minutes on a leg exercise stepper. But when it came to the range of motion exercises, the nursing assistant performed passive range of motion instead, moving the resident's joints himself rather than having the resident do the work.
"RNA 1 put his hand on Resident 54's elbow and wrists and performed passive range of motion to Resident 54's right shoulder, right elbow, right wrist, right fingers followed by PROM to Resident 54's left shoulder, left elbow, left wrist, and left fingers," inspectors wrote. "RNA 1 did not complete any AROM exercises for Resident 54's BUE or BLE."
When questioned, RNA 1 stated that Resident 54 had orders for active range of motion exercises for upper and lower extremities.
PT 1 explained the significance of the error to inspectors: "RNAs should be following the AROM exercise RNA orders as written in order for the residents to use their muscles and maintain their strength. Residents who could perform AROM exercises should not do passive ROM exercises, because the residents could get weaker or develop contractures."
Resident 54 told inspectors she would like to keep doing exercises for her arms and legs, noting that "walking did not help with the arms and legs."
The Director of Staff Development confirmed that nursing assistants should perform active range of motion exercises with Resident 54 "because that was the physician's order and that was the specific program that the rehabilitation department determined was appropriate." She added it was important for the resident to perform the exercises herself "because otherwise Resident 54 would rely on equipment or others to move their joints."
High-Risk Resident Falls Alone
The most serious incident involved Resident 77, a high-risk fall patient who was found sitting on the floor of his room at 12:38 a.m. on January 27 after falling from his wheelchair.
The resident had been admitted January 9 with stroke-related weakness on one side of his body, difficulty walking, lack of coordination, and depression. His care plan identified him as high risk for falls after he experienced two previous falls on January 22 and 23.
When inspectors arrived at the fall scene, they found Resident 77 sitting on the floor near his wheelchair with his call light lying on the bed out of reach. The resident said he didn't know how he got on the floor and denied being in pain. No facility staff were present in the room.
Registered Nurse Supervisor 1 told inspectors that Resident 77 had been brought to his room by wheelchair from the dining room before the fall. No staff witnessed the incident.
"Resident 77 was a high risk for falls and normally needed assistance with transferring from the wheelchair, the bed, and with ambulation to the bathroom," RNS 1 told inspectors. "If Resident 77 had assistance with transferring the resident would not have attempted to get out of the wheelchair by themselves and would not have fallen."
The nurse practitioner ordered Resident 77 transferred to the emergency room for evaluation. CT scans of the brain and neck showed no internal bleeding or injuries, and blood work revealed no acute abnormalities. The hospital cleared him to return to the facility.
The Director of Nursing confirmed that Resident 77 "needed frequent visual monitoring and supervision to prevent falls" and acknowledged "there was a potential for Resident 77 to fall again and develop an injury if the resident would not be adequately monitored and supervised."
Oxygen Without Orders
Inspectors also found Resident 230 receiving oxygen therapy without a physician's order. During an observation on January 27, the resident was receiving oxygen at two liters via nasal cannula with an unlabeled pre-filled humidifier.
Licensed Vocational Nurse 2 confirmed that both the nasal cannula and humidifier lacked proper labeling. When the Director of Staff Development reviewed the physician's orders the next day, she found no oxygen order for the COPD patient.
A physician's order for continuous oxygen was finally written on January 28 at 10:07 a.m., more than 24 hours after inspectors observed the resident receiving the treatment.
The Director of Nursing explained that unlabeled equipment posed risks of skin breakdown and symptom exacerbation if the humidifier ran out. She acknowledged that "for Resident 230, the standing order should have been initiated but it was missed upon the resident's admission."
Training Gaps
The facility's problems extended to staff competency verification. Inspectors found that annual competencies had not been completed for all six sampled restorative nursing aides who perform tasks including putting on and taking off splints and braces.
The facility's own policy states that splints must be applied correctly to maintain range of motion and prevent contractures. Without proper competency verification, residents requiring splints and braces face increased risks of injury, worsening contractures, and skin breakdown.
Resident 49 remains at the facility with severe sepsis complications and muscle wasting, dependent on staff for proper splint application to prevent further joint deterioration.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Guardian Rehabilitation Hospital from 2025-01-30 including all violations, facility responses, and corrective action plans.