Failure to Provide Ordered Restorative Nursing Program
Penalty
Summary
The facility failed to ensure that a restorative nursing program was provided as ordered for a resident with cognitive impairment and functional limitations in range of motion (ROM) in both upper and lower extremities. The resident, who had a history of muscle contractures and traumatic brain injury, was care planned to receive passive range of motion (PROM) exercises to the bilateral lower extremities daily. However, documentation from September 2024 through January 2025 revealed multiple instances where the PROM exercises were not completed as per the care plan. The Director of Nursing confirmed the lack of documented evidence for the completion of the PROM exercises on several specified dates. This deficiency was identified during a review of clinical records and interviews with staff, indicating a failure to adhere to the resident's care plan aimed at maintaining or improving their physical abilities.
Plan Of Correction
1. The medical record for R10 cannot be corrected. 2. The Director of Nursing or designee will audit current residents ordered passive range of motion (PROM) for documentation of completion. 3. The Director of Nursing or designee will re-educate nursing staff on the procedure for completion and documentation of passive range of motion (PROM) for the restorative nursing program (RNP). 4. The Director of Nursing or designee will audit 25% of passive range of motion (PROM) for completion and documentation of the restorative nursing program (RNP). The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.