Failure to Initiate Restorative Therapy Program
Penalty
Summary
The facility failed to initiate a restorative therapy program for a resident, identified as Resident #76, who was admitted with diagnoses including adjustment disorder, heart failure, muscle weakness, difficulty in walking, and acquired absence of right toe(s). The resident had moderately impaired cognition and required assistance with various activities of daily living. Despite the resident's expressed desire to continue therapy and denial of refusing therapy, the facility did not transition the resident to a restorative therapy program after the cessation of physical and occupational therapy. Interviews with the Therapy Manager and the Unit Manager/Restorative Therapy Nurse revealed a lack of communication and documentation regarding the resident's transition to restorative therapy. The Therapy Manager acknowledged the intention to place the resident in the restorative therapy program but noted a miscommunication that resulted in the plan not being documented in the medical records. The Unit Manager confirmed that no evaluation or referral for restorative therapy was received, despite the resident being a candidate for such a program. The Director of Nursing was informed of the communication breakdown and the failure to develop a restorative therapy plan for the resident. The facility's policy on restorative nursing emphasizes the importance of enabling residents to attain and maintain their highest practicable level of well-being through an interdisciplinary approach. However, the lack of a documented plan and communication between departments led to the resident not receiving the necessary restorative services.
Plan Of Correction
1. Resident #76 was evaluated and picked up by Physical and Occupational Therapy. 2. All residents discharged from PT or OT in the last 30 days were reviewed to ensure residents were started on a Restorative Therapy Program if ordered. 3. Therapy Director, Nursing Staff, and IDT team was educated on the Restorative Policy and Procedure as well as the ADL Policy and Procedure. 4. The Director of Nursing will audit all discharges from PT and/or OT weekly for four weeks, then monthly for two months to ensure restorative therapy programs were initiated as ordered. Any concerns will be addressed. Results of the audit will be reported to QA monthly. The Director of Nursing will be in charge of sustained compliance.