Failure to Provide Ordered Passive ROM for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received the necessary care and services to prevent further decline. The resident, who had a medical history of morbid obesity, unspecified joint contracture, rheumatoid arthritis, and difficulty in walking, had an order for rehabilitation services to perform passive ROM. However, there was no documentation that this order was completed. The resident expressed a desire for therapy to help with mobility, and although the doctor had ordered therapy, the resident had not received any services. Interviews with facility staff revealed a lack of communication and follow-through regarding the resident's care. The Physical Therapy Assistant indicated that the last documented visit with the resident was in 2023, and the Director of Staff Development and Human Resources was unaware of any order for restorative care. The Director of Nursing confirmed that staff should have communicated the doctor's order to the therapy department. A Certified Nursing Aide mentioned performing some passive ROM during transfers and showers but was unaware of the specific order for passive ROM. This lack of coordination and communication led to the resident not receiving the necessary care to maintain or improve their ROM.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #28 was evaluated by the therapy staff on 3/6/2025 and RNA program 3x a week or as tolerated for BUE/BLE PROM was started on 3/7/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: A comprehensive review of all residents' records performed by the Director of Nursing was started on 3/11/2025 to identify individuals with similar orders for restorative care that have not been followed. No other resident identified with the same findings/deficient practice. A weekly audit of MDS assessments and therapy orders will be implemented for all residents to ensure that any unaddressed restorative needs are promptly identified, and actions are taken. Affected residents will receive the necessary restorative interventions as determined by their care plans. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On 3/21/2025, the Director of Nursing Services in serviced the Licensed nursing staff to enhance communication protocols between nursing and therapy departments to ensure that all restorative therapy orders are communicated to therapy department. Medical Record will do a daily audit for orders established to review therapy orders and restorative care compliance. This will allow the nursing manager to verify if communication was sent to therapy department. Any gaps in this communication will be flagged immediately and nursing will follow up with therapy to ensure orders are seen and acted upon. How the facility plans to monitor its performance to make sure that solutions are sustained: The Director of Nursing with the IDT will implement monthly reviews/monthly recaps of restorative care compliance, which will include tracking the timely execution of therapy orders and resident feedback on the effectiveness of interventions. Outcomes related to restorative nursing services will be discussed in monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure ongoing accountability and improvement. A designated staff member will be assigned to oversee the restorative nursing program and oversee continuous monitoring for adherence to policies and procedures. Include dates when corrective actions will be completed: March 21st, 2025