Failure to Provide and Document Restorative Nursing Programs
Penalty
Summary
The facility failed to ensure that residents with limited mobility received appropriate services and assistance to maintain or improve their mobility. This deficiency was identified for three residents who were reviewed for limited range of motion. The facility's policy on Restorative Nursing Guidelines requires documentation of interventions, time spent, and patient tolerance, but this was not consistently followed. Resident 35, who has hemiplegia and hemiparesis following a stroke, was observed multiple times without a required palm guard, and there was a lack of documentation for their Restorative Nursing Programs. The Treatment Administration Records did not include the palm guard as an ordered treatment for January 2025, and there were several instances where the restorative programs were not documented. The DON confirmed the absence of documentation and the expectation that the programs should have been provided. Resident 40, who has muscle weakness and contracture, was discharged from occupational therapy and referred to a Restorative Nursing Program. However, there was no documentation of the program minutes or tolerance due to a change in electronic systems. Resident 50, with hemiplegia and hemiparesis, also had multiple instances where their Restorative Nursing Programs were not documented. The DON confirmed the lack of documentation for both residents and expected the programs to be provided as per facility policy.
Plan Of Correction
Unable to retroactively correct Resident 35's palm guard not being in place. Unable to retroactively correct failure to document Restorative Nursing Programs for Resident 35, Resident 40, and Resident 50. A comprehensive review of current residents with an active order for palm guards will be conducted to ensure that palm guards are in place as ordered. A comprehensive review of current residents with a restorative nursing program will be conducted to ensure that the restorative program has been completed and minutes documented. The facility will take further steps to ensure that the problem does not re-occur by in-servicing all nursing staff on F tag 688 with a focus on palm guards and restorative programming, as well as "Restorative Nursing Guidelines" policy. Compliance will be monitored by the Director of Nursing/Designee using the Palm Guard Audit and Restorative Nursing Program Audit to review 5 residents weekly for 3 weeks, then monthly for 2 months to ensure that palm guards are in place as ordered and that restorative programs are being completed and documented as ordered, with audit results being forwarded to the QAA committee to determine the need for further follow-up/monitoring.