Failure to Implement ROM Programs for Residents
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the range of motion (ROM) and mobility for three residents. Resident 65 had a therapy restorative referral indicating the need for active and active assisted range of motion exercises to be performed one to two times daily. However, the nursing staff did not implement the restorative nursing program until several days after the referral, and there were multiple dates where the program was not documented as completed. Resident 42 had impairments in her upper and lower extremities, and although a restorative ROM program was established, it was not initiated until nearly a month later, after the surveyor's intervention. Additionally, Resident 42 was supposed to have a splint brace program, which was also not implemented in a timely manner. Resident 70 had a limited ROM on one side of his body, and a ROM program was established for him as well. However, there was no evidence that the program was ever initiated. The Director of Nursing confirmed that the ROM program for Resident 70 was never started. These deficiencies were previously cited in earlier surveys, indicating a recurring issue with the facility's ability to provide adequate nursing services to maintain or improve residents' ROM and mobility.
Plan Of Correction
Cited: Residents 42, 65, and 70 range of motion programs were reviewed with IDT team and were reevaluated by therapy. - Like: The facility will complete a two-week look back on residents who were discharged from therapy to review if resident is appropriate for ROM program and ensure it is initiated. - Educations: DON/designee will educate nursing staff and ensuring ROM program recommendations from therapy are followed appropriately. - Audits: DON/designee will audit 5 residents weekly x 4 weeks then monthly x 2 months to ensure residents who are discharged from therapy have appropriate ROM programs initiated if appropriate. Results will be taken through QAPI.