Failure to Evaluate Restorative Nursing Program for Resident
Penalty
Summary
The facility failed to ensure that a resident received appropriate services and assistance to maintain or improve mobility with maximum practicable independence. Resident 6, who was admitted with diagnoses including diabetes and muscle weakness, was recommended for a restorative nursing program (RNP) after being discharged from physical therapy. The care plan included specific interventions for active and passive range of motion exercises. However, there was no nursing evaluation of the RNP program to assess the resident's progress or the need to revise the program from its inception in May 2024 through the end of the survey in December 2024. The Assistant Director of Nursing confirmed that RNP programs should be evaluated monthly and documented in the medical record, but admitted to not reviewing any programs since taking over in May 2024. The Nursing Home Administrator acknowledged the facility's responsibility to ensure residents receive appropriate services to maintain or improve mobility. This lack of evaluation and documentation led to the deficiency, as the facility did not adhere to its policy of providing necessary services to maintain or improve the resident's mobility.
Plan Of Correction
Documentation on resident 6 cannot be corrected. Resident 6 will have current restorative program evaluated for effectiveness and appropriateness. To identify residents with the potential to be affected, DON/designee will audit residents currently on restorative nursing to ensure nursing evaluation is present. To prevent from re-occurring, DON/designee will educate ADON on process for restorative initiation and regular documentation and evaluation. To monitor and maintain compliance, DON/designee will audit 5 resident charts weekly x 4 then monthly x 2 to ensure regular evaluation is completed on RNP. All results will be brought to QAPI committee.