Failure to Maintain Resident's Ambulation Program
Penalty
Summary
The facility failed to maintain or improve the ability of a resident to perform activities of daily living, specifically ambulation, due to insufficient staff follow-through. Resident 12, who was discharged from physical therapy with a home exercise program (HEP) and a good prognosis contingent on consistent staff support, reported that staff rarely assisted her with walking due to staffing shortages. Documentation revealed that on multiple occasions, staff marked the ambulation program as not applicable or noted the resident's refusal without re-approaching her to encourage participation. Throughout November 2024 to January 2025, there were numerous instances where Resident 12's ambulation program was either not attempted or marked as refused without further attempts to engage her. This lack of consistent follow-up and encouragement from staff resulted in the resident completing the program on only a fraction of the days reviewed. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to provide adequate care and services to maintain or improve the resident's functional abilities.
Plan Of Correction
1. Facility cannot retroactively provide restorative program to Resident 12 the days restorative was not completed. Resident 12 is currently receiving physical therapy. 2. DON/designee audited documentation from the last week of residents receiving restorative nursing program to verify residents are provided their program. 3. CNAs will be re-educated on the documentation of and providing restorative nursing services. 4. DON/designee will audit 5 random residents on a restorative nursing program weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.