Failure to Provide Appropriate Mobility Support for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services and assistance to maintain or improve mobility. Resident 27, diagnosed with Parkinson's Disease and muscle weakness, had a care plan that included specific interventions such as the use of an Ankle Foot Orthotic (AFO) for transfers and proper positioning in a Broda chair. However, observations revealed inconsistencies in the use of the AFO and leg rests, with the AFO often found on the floor rather than in use. Additionally, the resident's care plan indicated they were non-ambulatory, yet they were on a walking Restorative Nursing Program (RNP), which was not consistently documented or provided. The Physical Therapy Discharge Summary recommended a Restorative Nursing Program for sit-to-stand transfers and therapeutic exercises, but there was no mention of the AFO. Documentation from November 22 to December 11 showed gaps in the provision of range of motion and ambulation programs. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed confusion regarding the resident's ambulation status and the lack of documentation for the AFO. The NHA confirmed that the care plan should have been followed, and range of motion exercises should have been documented, highlighting a deficiency in the facility's adherence to the resident's care plan.
Plan Of Correction
1. R27's Restorative Nursing Program and nurse aide task documentation has been reviewed and revised to reflect discontinuation of ambulation and to continue with Transfers and ROM programming. Certified Nursing Assistants providing care on December 9, 2024, and December 10, 2024 have been re-educated on R 27's Care plan, and responsibility to provide equipment, devices and services in accordance with the resident care plan. 2. Residents receiving Restorative Nursing have been identified to validate current programs and nurse aide task documentation is reflective of current program needs and resident status. 3. The Registered Nurse Assessment Coordinators will be re-educated on role and responsibility of the Restorative Nursing Program to include revision of the resident care plan and validating proper documentation of devices and programming is in place. Nursing Staff will be re-educated on providing equipment, devices, and services in accordance with the resident care plan and on completing accurate documentation of care provided. Therapy staff will be educated in including functional devices and equipment in discharge summaries. A Weekly Restorative Committee has been established to review current programs, resident status, and documentation. 4. Weekly audits of at least 5 residents receiving Restorative Nursing per week will be conducted by the Director of Nursing or designee to validate current programming and task documentation is accurate and reflective of status. In addition, Director of Nursing or designee will conduct random observations of at least 5 residents per week to validate equipment and devices are in place per the resident care plan. Results of audits will be forwarded to the facility Quality Assurance and Performance Improvement Committee x 12 weeks for review and recommendation.