Failure to Prevent Decrease in Range of Motion
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for Resident R113. The resident, who was admitted with a history of stroke, anemia, end-stage renal disease, and a hip fracture, had a physician's order for weight-bearing as tolerated on the left lower extremity and non-weight bearing on the left upper extremity, with instructions to continue using a left arm sling when not exercising. However, the resident's care plan did not include any guidance on the removal of the sling or skin assessments related to its use. During an observation, Resident R113 was seen in the dining room wearing the sling on the left arm. Interviews with the Unit Director RN and the Assistant Director of Nursing confirmed that the facility did not have orders defining the removal of the sling or conducting skin assessments related to its use. This oversight led to the facility's failure to provide necessary treatment and services to prevent further decrease in the resident's range of motion.
Plan Of Correction
1. R113 plan of care was updated to include care relating to the use of a sling. 2. Director of nursing or designee will conduct a house audit of residents using slings to ensure plan of care includes care instructions related to the sling. 3. Director of nursing or designee will in-service license nurses on ensuring residents who utilize a sling have it included in their plan of care. 4. Director of nursing or designee will audit 3 residents weekly for 2 weeks, 2 residents weekly for 2 weeks, then 3 residents monthly for 2 months to ensure residents utilizing a sling have it included in their plan of care. Audit findings will be shared with QAPI committee.