Failure to Implement Restorative Nursing Programs
Penalty
Summary
The facility failed to provide necessary care and services to maintain or improve the ability to perform activities of daily living for two residents. Resident 5 was discharged from therapy on January 27, 2025, with recommendations for a restorative nursing program (RNP) that included sit-to-stands at grab bars. However, the RNP was not initiated until March 3, 2025, due to it being "missed," as confirmed by the Director of Therapy. This delay in implementing the RNP meant that Resident 5 was not receiving the recommended exercises to maintain her abilities during this period. Similarly, Resident 44 was discharged from skilled therapy services with a recommendation to continue with a restorative nursing program for ambulation, which included walking up to 100 feet with a roller walker and contact guard assistance. However, there was no evidence of an active RNP in her clinical record until March 5, 2025, after the surveyor's inquiry. The facility did not initiate the RNP for Resident 44's ambulation skills following the termination of skilled therapy services, as confirmed by the Nursing Home Administrator.
Plan Of Correction
1. Resident 5 and 44 were unharmed. Resident 5 is currently completing an RNP program. Resident 44 is currently completing an RNP program. 2. The Therapy Director completed an audit on any residents discharged from therapy services to indicate if they needed or had an RNP program in place. 3. The Therapy Director conducted an education with the therapy staff to ensure that the RNP is implemented upon the patient's discharge from therapy services, if necessary. 4. The Therapy Director or designee will conduct weekly audits for a duration of four weeks, followed by monthly audits for three months, to verify the implementation of the RNP for the resident, if required. The Therapy Director will bring the audit to the monthly QA meeting for review.