Highland Hills Post Acute discharged Resident R4 from therapy on September 4, with specific instructions for evening and morning splint care. Twenty days later, federal inspectors found the right resting hand splint sitting in the bedside stand while the resident lay in bed without any splints on either hand.
The resident suffered from stroke, hemiplegia, and aphasia. The paralysis of one side of their body made the hand splint critical for maintaining functional positioning and preventing further mobility decline.
Director of Rehabilitation Employee E12 told inspectors the resident had been moved to the Rehab Restorative transition program with clear instructions: right resting hand splint on in the evening and off in the morning. The rehabilitation department had provided written documentation of these requirements.
But the facility never processed the transition recommendations.
Inspectors found no physician orders for the hand splint use. The resident's care plan, reviewed on September 24, contained no mention of splint care requirements. The rehabilitation department's specific instructions had vanished from the resident's official treatment protocol.
"The facility is working on the processes for when a resident transfers from rehab to a long term care unit," the Director of Nursing admitted to inspectors. The statement confirmed what inspectors had documented: Highland Hills Post Acute had failed to ensure the stroke patient received appropriate equipment and assistance to maintain mobility.
The facility's own policy, dated November 1, 2024, required staff to maintain and supervise the use of assistive devices and equipment for residents. Federal regulations mandate that nursing homes provide appropriate care to maintain or improve range of motion and mobility unless decline results from medical reasons.
For Resident R4, the decline wasn't medical. It was administrative.
The hand splint represented more than a piece of equipment. For stroke patients with hemiplegia, these devices prevent contractures and maintain hand positioning that can mean the difference between retained function and permanent disability. The evening application allows muscles to rest in proper alignment overnight, while morning removal permits daytime movement and therapy activities.
The rehabilitation team had recognized this need and created a transition plan. They documented the requirements and handed them to the facility's long-term care unit. Then the system broke down.
No one entered physician orders. No one updated the care plan. No one trained nursing staff on the splint schedule. The device that could help maintain the resident's remaining hand function sat inches away, unused.
The inspection occurred during a complaint investigation, suggesting someone had raised concerns about care quality at Highland Hills Post Acute. Federal inspectors examined four residents' mobility care and found this failure in one case, indicating broader systemic issues with rehabilitation transitions.
The Director of Nursing's acknowledgment that the facility was "working on the processes" revealed the problem's scope. This wasn't an isolated oversight but a gap in the facility's procedures for moving residents between levels of care. Other residents making similar transitions could face the same abandonment of their rehabilitation recommendations.
Highland Hills Post Acute operates at 1105 Perry Highway in Pittsburgh, serving residents who require both short-term rehabilitation and long-term care. The facility's policy manual promised to maintain and supervise assistive devices, but the promise meant nothing without implementation.
For Resident R4, each day without the prescribed splint schedule represented potential loss of function that might never return. Stroke recovery operates on narrow windows of opportunity, and rehabilitation equipment serves as a bridge between therapy sessions and daily life.
The hand splint in the bedside stand told the story of a system that processed paperwork but lost sight of the person. Rehabilitation professionals had assessed the resident's needs, prescribed specific interventions, and documented clear instructions. The facility had policies requiring equipment supervision and mobility maintenance.
Yet the resident lay in bed without the prescribed care, while the device that could help preserve their remaining function gathered dust within arm's reach.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Hills Post Acute from 2025-09-25 including all violations, facility responses, and corrective action plans.