Failure to Provide Restorative Nursing Programs for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain or improve the range of motion and mobility for two residents with limited range of motion. Resident R7, who was admitted with conditions including paraplegia, multiple sclerosis, and muscle contractures, was observed with his left arm in a fixed position on his chest. Despite having a restorative nursing program in place, which included passive range of motion exercises and splinting, there was no documented evidence that these interventions were provided to Resident R7. This was confirmed by an interview with the Assistant Director of Nursing. Similarly, Resident R37, who was admitted with a history of cerebrovascular accident and hemiplegia, was not receiving the recommended restorative nursing program. The occupational therapy discharge summary recommended a splint and brace program, but there was no documentation that this was implemented. Observations revealed that Resident R37's left upper and lower extremities were limp, and interviews confirmed that the resident was not receiving the necessary splinting as prescribed. The lack of documentation and implementation of the restorative nursing programs for both residents indicates a failure by the facility to ensure that residents with limited range of motion receive appropriate treatment and services. This deficiency was identified through observations, clinical record reviews, and staff and resident interviews, highlighting a significant oversight in the care provided to these residents.
Plan Of Correction
1. On 12/26/2024 the nurse management team reviewed all residents that have nurse maintenance programs for splinting and implemented sign off sheets for the nurse maintenance programs for Resident R7 and Resident R37. 2. On 12/26/2024 the nursing management team reviewed the electronic health record of residents on a nurse maintenance program for splinting program and verified that proper documentation was present. 3. The IDT team will review new residents on a maintenance program for splinting during clinical meetings to verify documentation is present for maintenance programs. 4. Education on maintaining complete documentation for nursing maintenance programs will be presented by the DON/designee to all CNA staff by 1/16/2025. 5. The DON/designee will conduct audits on nursing maintenance nursing program for splinting documentation for 4 weeks and monthly for 3 months. Results of the audits will be reviewed at the QAPI meeting held monthly.