Inadequate Restorative Care Due to Staffing Shortages
Summary
The facility failed to provide adequate restorative care services to a resident, identified as Resident #9, who required assistance to maintain and improve range of motion (ROM) due to conditions such as Multiple Sclerosis, paraplegia, and epilepsy. The resident's care plan, initiated in November 2022, specified that restorative therapy staff should provide bilateral lower and upper extremity ROM and stretching 1-5 times per week. However, a review of the Restorative Nursing Flow Sheets from June to August 2024 revealed that the facility did not provide the required programming for five weeks during this period. Interviews with the resident and staff highlighted staffing issues as a significant factor contributing to the deficiency. The resident reported that restorative care was not being provided due to a lack of available staff. Staff A, a Certified Nursing Aide/Restorative Nursing Aide, confirmed that she was often pulled to work on the floor, which prevented her from completing restorative care as needed. The Director of Rehab and the Director of Nursing acknowledged the staffing challenges, noting that the facility had only one person available for restorative care, leading to unmet care frequencies. The facility's policy required restorative care to be performed as ordered, but staffing shortages hindered compliance with these directives.
Penalty
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A resident admitted with multiple upper extremity fractures was repeatedly observed wearing a right arm sling without a corresponding physician order or care plan. An LPN confirmed there was no order for the sling, and review of the clinical record verified the absence of any documented order or care plan for its use. The Nursing Home Administrator acknowledged that the facility failed to ensure appropriate medical authorization and documentation for the sling, resulting in noncompliance with state requirements for resident care and nursing services.
A resident with hemiplegia and hemiparesis after a cerebral infarction, and severe cognitive impairment (BIMS 5), had physician and therapy orders for right-hand and right-ankle splinting with passive ROM to manage contractures and maintain ROM. Surveyors observed a foot splint lying unused and the resident’s right hand contracted into a fist without a hand roll. The resident could not recall when the foot splint was last applied and reported never having a hand roll. An LPN was unaware of the need for the splint and confirmed no hand roll was in use. Records showed the hand splint order was discontinued at the responsible party’s request due to pain, but OT was not notified and no alternative such as a hand roll was initiated. PT had documented improved ankle ROM and recommended a PODUS boot, while a PTA later reported the resident had developed foot drop related to the ankle splint not being applied as ordered. The DON confirmed that daily ankle splint orders existed and that the hand splint was discontinued without alternative interventions to prevent contracture.
Two cognitively intact residents with significant ROM and mobility limitations did not receive their care-planned restorative nursing programs as ordered. One resident with DM, neuropathy, above-knee amputation, and CKD reported increasing stiffness and weakness and stated that staff no longer brought her for exercises; records showed only sporadic lower extremity and kinetic bike sessions over several months despite physician orders and a care plan for regular AROM and restorative activities. Another resident with RA, polyneuropathy, and prior fractures, who used a power wheelchair, reported not receiving her prescribed exercise program and feeling she was losing strength; her MDS and restorative documentation showed no completed restorative exercises or standing with a walker despite a detailed restorative care plan. Therapy staff and RAs confirmed written restorative recommendations and expectations for 3–6 sessions per week, but reported that two RAs were responsible for about 44 residents, could not see all residents daily, prioritized those more willing or independent, and were unsure when these two residents last received restorative exercises, while the DON acknowledged awareness of staffing difficulties and confirmed the minimal restorative services actually provided.
Two residents with neurological impairments and contractures did not consistently receive prescribed cervical collars and a mechanical back/cervical splint during bedrest and meals. One resident, ordered to wear a soft cervical collar in bed and for all meals for neck contracture management, was repeatedly observed without the collar, which was found on the bedside stand, and her care plan and CNA Kardex lacked instructions for its use or refusal despite documentation that she preferred wearing it. Staff gave conflicting accounts about whether the collar was still in use, and there was no documentation of refusals as required by facility policy. Another resident, ordered to wear a cervical brace during all meals, was repeatedly observed with her head leaning to one side, without the brace, and not eating, while CNAs reported the brace’s Velcro failed and her head slipped out despite repeated attempts to reposition and reapply it. Therapy and restorative staff acknowledged ongoing issues with the brace, missed reassessment, and lack of reported concerns, contrary to facility policy requiring regular assessment and reporting of problems with assistive devices.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with deforming dorsopathy and gait/mobility abnormalities had a PT discharge recommendation and care plan goal for a restorative ambulation program, including supervised walking with a rolling walker throughout the unit twice daily. Facility policy required patient-specific restorative programs to be implemented per the care plan, but restorative documentation repeatedly showed the ambulation program as "not applicable" over multiple days, and the resident reported being assisted to walk in the hallway only a few times since therapy discharge. The DON later noted that the restorative program was incorrectly titled in the EHR, potentially confusing CNAs, and although the POC task was corrected to specify walking 100–150 ft, staff continued to document the program as "not applicable," indicating the restorative ambulation services were not being provided as planned.
Lack of Physician Order and Care Plan for Resident Sling Use
Penalty
Summary
Surveyors found that the facility failed to obtain a physician order for the use of a right arm sling for a resident with limited mobility. The resident was admitted with diagnoses including a displaced fracture of the surgical neck of the right humerus, a closed fracture, and a fracture of the lower end of the left radius. On two separate observations, the resident was seen wearing a right arm sling. During an interview, an LPN confirmed that there was no physician order for the sling, and review of the clinical record showed no physician order or care plan addressing the resident’s sling use. The Nursing Home Administrator acknowledged that the facility failed to ensure a resident with limited mobility had a physician order for the sling, in violation of applicable Pennsylvania regulatory requirements for licensee responsibility, resident care policies, and nursing services.
Failure to Implement ROM and Splinting Orders Resulting in Contractures and Foot Drop
Penalty
Summary
The facility failed to provide ordered range of motion (ROM) and splinting interventions to prevent decline in ROM for a resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident was admitted with these diagnoses and had physician orders and therapy recommendations for contracture management and splinting. An OT evaluation documented decreased ROM in the right upper extremity and recommended a resting hand splint and a restorative splint and brace program, with a subsequent OT evaluation recommending continuation of the contracture management and splinting program. A physician order directed staff to apply a right-hand splint after breakfast, provide passive stretch to the right elbow, wrist, and hand once daily, and remove the splint before dinner. Another physician order required application of a right ankle splint after breakfast and after supper with passive stretching following application. The facility’s own policy stated that residents without limited ROM should not experience a reduction in ROM unless clinically unavoidable. During observation, surveyors noted a foot splint lying unused in the resident’s chair and the resident’s right hand contracted into a fist without a hand roll in place. The resident reported not knowing when the foot splint was last applied and stated she had never had a hand roll. An LPN stated she did not know why the splint was in the room, believed the resident was not required to wear it, and confirmed the resident did not have a hand roll. Record review showed the right-hand splint order was discontinued at the responsible party’s request due to pain, but the OT reported she had not been notified of this discontinuation and stated a hand roll should have been initiated when the splint was stopped; she further stated the resident’s hand was now contracted into a fist. A PT discharge summary documented improved right ankle ROM with therapy and recommended a PODUS boot daily for up to five hours, while a PTA later reported the resident had developed foot drop and that the ankle splint could no longer be applied without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON verified that there were physician orders for daily ankle splinting and acknowledged that the right-hand splint was discontinued without alternative interventions to prevent contracture. The resident’s MDS showed a BIMS score of 5, indicating severe cognitive impairment.
Failure to Provide Planned Restorative Nursing Programs for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide ongoing restorative nursing programs as care planned and ordered for two cognitively intact residents with limited ROM and mobility. One resident, with Type 2 DM with diabetic neuropathy, an above-knee amputation, adjustment disorder with depressed mood, and stage 4 CKD requiring dialysis three times weekly, reported frustration that the fingers on her right hand were stiff and that she could no longer make a fist. She stated she felt weaker and believed she was not receiving the exercises she needed, explaining that she previously had exercises but no longer was brought for them. She reported that when she complained to therapy about not getting her exercises, she was told that restorative nursing aides were now responsible for providing them. Record review for this resident showed a physician note directing staff to encourage participation in restorative activities and a physician’s order for staff to encourage restorative activity three times weekly with a progress note to be completed on day shift when done. Her care plan included participation in restorative therapy with a goal to maintain current functional ability and interventions of AROM per therapy and nursing recommendations. Her MDS documented functional limitations in ROM in one upper and one lower extremity and indicated she received only two days of AROM restorative nursing programs in the seven-day look-back period. Restorative documentation from mid-December through late March showed that for lower extremity exercises she was documented as not available on multiple days, refused on several days, and not applicable on others, with only two days of restorative lower extremity exercises provided. For kinetic bike exercises over a three‑month period, she was documented as not available or refusing on multiple days, with several days marked not applicable, and only four days of kinetic bike restorative exercises completed. A second resident, who used a power wheelchair, had limited use of upper and lower extremities, and diagnoses including rheumatoid arthritis, polyneuropathy, and fractures of the right lower leg and foot, reported via an iPad translation device that she had participated in PT on admission and was discharged to a restorative program. She stated she was upset that she had not been receiving her exercise program, had complained to the DOR, and felt she was losing strength and her ability to stand and transfer. Her BIMS score indicated she was cognitively intact. Her MDS showed functional limitation in ROM in one lower extremity and no restorative nursing exercise programs received. Her care plan called for participation in a restorative therapy program to maintain functional abilities, with interventions including AROM, sitting exercises with a 3‑lb green TheraBand, trunk exercises x15 reps, and transfers involving standing with a walker up to 10 minutes. Restorative documentation from late January through late March showed multiple refusals and days marked not applicable, with no documentation that she received lower extremity exercises or stood with her walker for ten minutes during that period. Interviews with therapy staff and restorative aides revealed that therapy had provided written restorative recommendations on transfer forms, and the DON was responsible for setting up the programs. The therapy team expected two restorative aides to complete the recommended exercise programs, including upper and lower extremity exercises three to six times per week for the first resident (arm bike, recumbent kinetic bike, 5‑lb weights, green bands) and a lower extremity program three to six times per week for the second resident (standing with walker for ten minutes, 3‑lb weights, green bands). One restorative aide reported that she and the other aide were responsible for restorative exercises for about 44 residents, each scheduled for 15 minutes daily, and that it was impossible to see all residents when only one aide was working. She stated some residents were prioritized because they were ready, independent in getting to the exercise room, and enjoyed exercising, while others known to refuse were deprioritized when staff were busy. She acknowledged not having completed restorative exercises with the first resident recently and not having done restorative exercises with the second resident in over a month. The other restorative aide confirmed workload challenges, restrictions on being alone with the first resident, difficulty coordinating use of the main therapy room and equipment, and uncertainty about when either resident last received restorative exercises. The DON and regional nurse consultant confirmed that the facility’s policy defined restorative nursing as interventions to promote optimal functioning, that residents with written programs were expected to receive at least 15 minutes per day, and that the first resident had received only seven days of restorative exercises since mid‑December while the second resident appeared to have received none since late January, and they were unaware of the residents’ concerns.
Failure to Provide and Maintain Prescribed Cervical Collars and Splints for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and maintain prescribed cervical collars and a mechanical back/cervical splint for two residents with significant neurological and musculoskeletal impairments. For one resident with a history of cerebral infarction, right middle cerebral artery occlusion, and left-sided hemiplegia/hemiparesis, surveyors repeatedly observed her in bed without the ordered soft cervical collar in place, despite a physician’s order that she wear the collar while in bed and for all meals for neck contracture management. The collar was seen on the bedside stand during one observation, and the resident’s care plan and CNA Kardex contained no instructions regarding use or refusal of the collar. The NP’s earlier progress note documented that the resident liked wearing the collar and wanted to wear it more frequently than ordered, and there were no subsequent notes documenting refusal or discontinuation. Staff interviews further showed inconsistent understanding and implementation of the collar order for this resident. A CNA reported believing the collar had been discontinued after a trial for meals only, stating it was unsuccessful and that she understood it was no longer in use. The DON stated the collar had been used when the resident was eating meals consistently, but that it was not being used because the resident was now being offered food for pleasure only and was expected to receive a feeding tube. The DON also stated the collar was in the laundry because it was dirty and acknowledged that refusals should have been documented and that frequent refusals should have triggered re-evaluation of the device. The Director of Therapy confirmed the collar had been implemented for a right-sided neck contracture and that the resident initially wanted to wear it more often, and indicated that documentation of refusals was the responsibility of nursing. The facility’s policy on braces and assistive devices required documentation of refusals, follow-up actions, and care plan updates addressing device type, application instructions, monitoring guidelines, and specific risks, which were not reflected in the record. For a second resident with diagnoses including unspecified intracranial injury, left-sided hemiplegia, and traumatic subarachnoid hemorrhage, surveyors repeatedly observed her during meals with her head leaning to the left, without the prescribed mechanical back/cervical splint in place, and with full or covered meal trays that she was not eating. Her care plan identified an ADL self-performance deficit and included an intervention for application of a cervical/back splint during meals and removal afterward. Physician orders directed that she wear a cervical brace during all meals, angled approximately 30 degrees in extension with a towel under the brace. However, the most recent MDS did not indicate use of splints or braces, and staff interviews revealed ongoing problems with the brace’s fit and function that were not effectively addressed. CNAs reported that the resident should have had the brace on but that her head repeatedly slipped out of it, even after attempts to reposition her and reapply the brace, and one CNA stated she was unsure whether the NP or therapy had been notified. Another CNA described the Velcro on the brace releasing and the resident sliding in her seat so that the brace could not support her head, and indicated she had not been instructed on alternative interventions if the brace was ineffective and was unaware of any notification to NP or therapy. The Director of Therapy stated that therapy was initially responsible for the brace and that, after discharge, restorative nursing managed issues, with therapy performing screenings every three months; she acknowledged awareness that the Velcro continued to come undone but did not describe additional actions to ensure the brace was safe and properly fitting. The restorative nurse reported that Velcro had been replaced earlier in the month and that staff had not reported ongoing issues. The DOT later stated that the resident had been missed for a scheduled reassessment that should have occurred approximately three months after the last assessment and that she was on a list for reevaluation while therapy awaited an order. The facility’s policy required assessment of braces and assistive devices on admission, with changes in condition, and periodically as part of the care plan process, with nursing staff reporting changes in mobility or tolerance and reassessment quarterly with MDS review, which was not consistently carried out for this resident.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Restorative Ambulation Program for Resident With Limited Mobility
Penalty
Summary
The facility failed to provide appropriate restorative nursing services to maintain or improve range of motion and mobility for a resident with limited mobility. Facility policy on Restorative Nursing required that restorative programs be patient-specific and implemented according to the care plan to promote the patient’s ability to live as independently and safely as possible. The resident’s diagnoses included deforming dorsopathy and abnormalities of gait and mobility. A physical therapy discharge summary documented that the resident was to be referred to a restorative ambulation program to provide supervision and support for longer-distance ambulation with a rolling walker on the unit to attend activities. The resident’s care plan included a restorative ambulation focus with a goal for the resident to walk throughout the unit at least two times per day. Despite these orders and care plan interventions, restorative nursing documentation for the resident showed the program was repeatedly marked as “not applicable” on numerous dates, indicating that the restorative ambulation program was not being carried out. The resident reported that since discharge from therapy, she had only been assisted to walk in the hallway with her walker two to three times and expressed that it would be nice to walk every day. The DON later stated that the restorative program was titled incorrectly in the electronic system, which could have caused confusion for nurse aides, and that the task had been updated to reflect walking 100–150 feet. However, even after this correction, the restorative program continued to be documented as “not applicable,” and the DON acknowledged he would need to follow up on why the program was still not being implemented as expected.
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