Failure to Provide Ordered Range of Motion Exercises
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the necessary treatment and services to maintain or prevent further decrease in their range of motion. This deficiency was identified during a complaint and recertification survey. Specifically, a resident who was cognitively intact and required assistance with activities of daily living was not provided with range of motion exercises as ordered by their physician. The resident had been ordered to receive active range of motion exercises for both upper extremities and active/passive range of motion for both lower extremities, but these exercises were not being performed as required. Interviews with staff revealed a lack of awareness and execution of the resident's care plan. Certified Nursing Assistants (CNAs) assigned to the resident were not performing the exercises, and there was confusion regarding the resident's inclusion in a restorative nursing program. Documentation inaccurately reflected that exercises were being completed, despite staff acknowledging that they were not providing the exercises. The Director of Nursing Service noted that unit nurse supervisors are responsible for reviewing care plans with staff and ensuring care is provided, indicating a breakdown in communication and oversight within the facility.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? - Resident # 66 was assessed by OT on (2/27/2025) and had no negative outcomes from the deficient practice. - Task in CNA Accountability (Point Of Care) was revised to provide clear instructions pertinent to Range of Motion exercises on 2/27/2025. - Certified Nursing Assistant # 9 was re-educated on the following plan of care listed in electronic Kardex on 2/27/2025. - Certified Nursing Assistant # 11 was re-educated on the accuracy of documentation on 2/27/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - All residents on restorative nursing care have the potential to be affected by this practice. - An audit is being conducted on all residents on the Restorative Nursing Care to ensure the tasks are documented accurately based on actual provision of care. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: - The facility Policy and Procedure titled “Rehabilitative Nursing Care” was reviewed and revised to ensure restorative nursing care provided and accurately documented. - All nursing staff are being in-serviced on the above policy and procedure with an emphasis on the importance of the completion of the restorative care and accurate documentation of such. - All RNs and therapists are being re-educated on proper entry of restorative nursing tasks into EHR. - Weekly restorative nursing care meetings are being initiated to ensure the ordered restorative care is provided and documented. - The audit tool was created to ensure compliance. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? - On a weekly basis for the first quarter, the Director of Nursing, or designee, will randomly observe and audit 3-5 residents on the restorative nursing care for the completion of task and accurate documentation. Any outstanding issues will be addressed immediately and reported to the Administrator. - On a monthly basis, Director of Nursing will report the findings to the Administrator. - On a quarterly basis, Director of Nursing will report findings to QAPI Committee. - QAPI Committee to determine if further action is required. 5. The title of the person responsible for correction of each deficiency: Director of Nursing & Assistant Dir. of Nursing.