Resident 118 was supposed to have his left hand washed, dried, and fitted with a splint every morning to prevent contractures, according to physician orders dating back to May 2021. Staff were instructed to remove the device at bedtime on the second shift.
When inspectors observed the resident sitting up in his bed at 2:15 p.m. on September 17, the splint was nowhere to be found.
Licensed Practical Nurse 3 confirmed what inspectors already knew. The splint wasn't on the resident's hand. More troubling, she told them at 2:29 p.m. that she couldn't locate the device anywhere.
The resident's care plan, established in December 2017, specifically outlined the daily routine: wash and dry the left hand, apply the splint with morning care, remove on second shift. The August quarterly assessment revealed Resident 118 was dependent on staff for all daily care needs due to cognitive impairment.
Director of Nursing confirmed the obvious during her interview at 3:55 p.m. The resident's left hand splint should have been applied with morning care, just as the physician had ordered more than four years earlier.
The violation represents a failure to provide appropriate care to maintain range of motion and prevent contractures, unless decline occurs for medical reasons. For Resident 118, no medical reason existed to skip the ordered splint application.
Contractures occur when muscles, tendons, or ligaments shorten and tighten, limiting joint movement and causing pain. Hand splints are specifically designed to maintain proper positioning and prevent these debilitating complications in residents who cannot move independently.
The missing splint incident occurred despite clear documentation across multiple care planning documents. The physician's order from 2021 remained active. The care plan from 2017 provided step-by-step instructions. The August assessment confirmed the resident's continued need for total assistance with daily activities.
Yet when inspectors arrived, staff had no idea where the medical device was located.
The facility's failure affected one of 68 residents reviewed during the inspection. Federal regulators classified the violation as causing minimal harm or potential for actual harm to few residents.
Pennsylvania nursing home regulations require facilities to provide nursing services that meet professional standards of quality. The missing splint violation directly contradicted these requirements.
Resident 118's situation illustrates how basic medical equipment can simply disappear from a nursing home's daily care routine. The splint wasn't broken or being repaired. It wasn't temporarily removed for a medical procedure. Staff simply couldn't find it when inspectors looked.
The four-year gap between the care plan's creation and the physician's order suggests this resident had required contracture prevention for an extended period. The August assessment confirming cognitive impairment and total dependence on staff meant Resident 118 couldn't advocate for himself or remind staff about the missing splint.
Licensed Practical Nurse 3's inability to locate the device during the afternoon shift raises questions about communication between nursing shifts and equipment tracking procedures. If the splint should have been applied during morning care and removed during second shift, multiple staff members should have known its location.
The Director of Nursing's confirmation that the splint should have been applied suggests facility leadership understood the requirement but failed to ensure compliance. Her acknowledgment came nearly two hours after the Licensed Practical Nurse admitted she couldn't find the device.
Federal inspectors documented the violation under regulations governing range of motion and mobility maintenance. The citation specifically addresses facilities' responsibility to provide appropriate care unless medical reasons justify decline.
For Resident 118, no medical contraindication existed for splint use. The physician had ordered it. The care plan required it. The resident's condition necessitated it.
The splint simply wasn't there when it should have been.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ridgeview Healthcare and Rehabilitation Center from 2025-09-18 including all violations, facility responses, and corrective action plans.
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