The resident, identified as R31 in federal inspection records, told investigators that nurses and certified nursing assistants used to apply bilateral hand splints during the day, but stopped after the facility conducted a deep cleaning nearly a year ago. The resident suspected staff threw out the splints by mistake and said they informed staff about the missing equipment, but it was never replaced.
When inspectors observed the resident on September 9, they found the person sitting at the bedside with left fingers closed inward. The resident explained that both hands had weakness, with the left side being worse, and demonstrated being able to spread the left fingers open using the right hand.
Medical records show the resident has been prescribed hand splints since October 2023, with orders stating the resident "may wear splint to bilateral upper extremities as tolerated and as needed for comfort." The resident's care plan, revised in April 2024, specifically addresses orthoses related to rheumatoid arthritis and includes interventions to educate on the importance of wearing splints and monitor them for cleanliness and proper fit.
Despite these documented requirements, progress notes from 2025 prior to the inspection made no mention of hand splints or braces. The electronic medical records also contained no references to hand braces or splints under activities of daily living tasks.
Multiple staff members confirmed the resident had been without hand splints for an extended period. A nurse who works with the resident most days of the week told inspectors that while the resident had splints years ago, there were none this year. The nurse said they had been caring for the resident since the person moved to the first floor of the facility.
A certified nursing aide who provides care to the resident on most days confirmed the resident cannot hold the left fingers open all the time, noting that the left fingers are closing inward. The aide said the resident had not had hand splints or braces for more than a year.
The facility's restorative nurse acknowledged that the nursing home did not reorder the hand splints until the day of the inspection. A psychiatric rehabilitation services coordinator who had worked with the resident for less than half a year said they had never seen the resident with hand splints during morning rounds.
Even the director of nursing confirmed not seeing hand splints or braces on the resident during routine rounds.
The facility's own policy on splints, braces, and devices states that residents with conditions including "weak or absent muscle strength" may be eligible for evaluation. The policy requires nursing and restorative staff to document the application of splints, braces, or devices on appropriate facility forms.
The resident's primary diagnosis is rheumatoid arthritis, a condition that commonly causes joint deformities and requires supportive devices like hand splints to prevent contractures and maintain function. Without proper splinting, fingers can gradually curl inward and lose mobility, as observed in this case.
The inspection found that Park View Rehab Center failed to reasonably accommodate the needs and preferences of the resident by not providing the prescribed hand splints. Federal inspectors classified this as minimal harm or potential for actual harm.
The violation represents a breakdown in multiple systems at the facility. Staff failed to replace essential medical equipment after it was accidentally discarded, despite the resident's repeated requests. The nursing staff responsible for applying the splints did not escalate the missing equipment issue. Progress notes failed to document the absence of prescribed medical devices, and supervisory staff did not notice during routine rounds that a resident was missing prescribed orthotic equipment.
The case illustrates how seemingly minor oversights in nursing home operations can have lasting consequences for residents' health and function. For someone with rheumatoid arthritis, hand splints are not merely comfort items but essential tools to prevent permanent deformity and maintain independence in daily activities.
The facility only took action to reorder the hand splints on the day federal inspectors arrived, more than a year after the resident first reported them missing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park View Rehab Center from 2025-09-12 including all violations, facility responses, and corrective action plans.