Nursing neglected to assess, document and provide continuous treatments for Z1's hands. Z1 is a 47 year old female with a diagnosis of severe mental retardation, Autism, Behavior Disorder and Depression. She is noted to be independent with supervision for eating, tooth brushing, bathing, dressing and hair care. Notes reveal Z1 required staff to feed her, brush her teeth, bath and dress her and provide hair care. Z1's fine and gross UE motor skills were drastically reduced due to bilateral hand contractures.
Notes indicate an increase in falls.
The cast was therefore prematurely removed. Nursing failed to have a copy of the physician note in the file. This should be done before any more time is wasted and more damage done. Z2 explained that she had written many such notes to the facility. There is no evidence in Z1's file of nursing requesting a follow up for the left hand to ensure proper healing.