Failure to Provide Daily Ambulation for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to maintain or improve their mobility. Specifically, the resident, who was cognitively intact and required supervision for ambulating, was not ambulated daily as recommended in their care plan. The resident had diagnoses of lymphedema and chronic pain syndrome and was on a nursing rehab ambulation program that required stand-by assistance for walking 10 to 15 feet with a rolling walker. However, records showed that the resident was only walked on a few specific dates over a month-long period, contrary to the daily ambulation plan. Interviews with the resident and staff revealed that the resident expressed concern about not being walked regularly, fearing a loss of mobility. Staff members, including a Certified Nurse Aide and the Registered Nurse Unit Manager, acknowledged that due to staffing shortages, the ambulation program was not consistently implemented. The Director of Rehabilitation and the Director of Nursing both stated that they expected staff to follow the care plan, which included daily ambulation for the resident. The failure to adhere to the care plan was attributed to insufficient staffing, which hindered the ability to provide the necessary care to maintain the resident's mobility.
Plan Of Correction
Plan of Correction: Approved February 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #51 was reassessed by therapy to ensure there was no decline in residents' ROM or abilities, which revealed there were no changes in ADL abilities. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents who are care-planned for an ambulation program are at risk for the same deficient practice. All residents with an ambulation program will be reviewed to ensure ambulation programs are appropriate and being completed as planned. Any adjustments required to the plan will be made at that time. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? To ensure residents receive appropriate treatment to prevent decline, the facility’s Ambulation Program policy was reviewed, and no changes were identified to be needed. All nursing staff responsible for implementing and overseeing ambulation programs will be re-educated on the facility's policy. The therapy department will provide a weekly list to the nursing department indicating what residents are care planned for an ambulation program. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? Unit Managers will conduct weekly audits for 1 month, then monthly audits for a period of 2 months, verifying that ambulation programs are being implemented. Audits will include documentation review, as well as resident interviews. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The Director of Nursing will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.