Failure to Prevent Decline in Joint Range of Motion
Penalty
Summary
The facility failed to provide appropriate services to prevent a decline in joint range of motion (ROM) for two residents with limited ROM. Resident 3 did not receive timely quarterly Rehabilitation Joint Mobility Assessments (JMA) to monitor changes in joint ROM. The Director of Rehabilitation acknowledged that the last JMA for Resident 3 was completed on 11/20/2024, and another was due by February 2024, which was not completed. This delay in assessment could hinder the early detection of contractures, which are crucial to prevent further decline in ROM. Resident 27 was supposed to have a left elbow extension splint placed five days a week, as per physician orders. However, the Medication Administration Record (MAR) indicated that the splint was not placed on several occasions in February and March 2025. Both the Restorative Nurse Assistant and a Registered Nurse confirmed the absence of documentation for the splint application on these dates, which could lead to a decline in the resident's left elbow condition. The facility's policies and procedures require staff to identify the resident's current ROM and ensure the application of splints to prevent contractures. The failure to adhere to these policies for both residents could potentially lead to further decline in their joint mobility and overall quality of life.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, the Director of Rehabilitation (DOR) completed Resident 3's joint mobility assessment. Based on the assessment, Resident 3 did not experience any negative outcome or adverse reaction in functional ability as a result of this deficient practice. On 3/7/25, Resident 27's order was clarified to allow the Restorative Nursing Assistant (RNA) to provide the extension splint as ordered. From 3/7/25 to 3/15/25, Resident 27 was provided her extension splint on 3/8/25, 3/11/25, 3/12/25, 3/13/25, 3/14/25, and 3/15/25. On 3/18/25, Resident 27 was transferred to the hospital for unrelated reasons. 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: All residents have the potential to be affected by this deficient practice. On 3/5/25, the DOR/designee conducted an audit on all active residents for quarterly joint mobility assessments. No other residents were affected by this deficient practice. On 3/13/25, the Medical Records Director conducted an audit on all active residents who have splint orders and compared it to the restorative nursing assistant documentation. No other residents were affected by this deficient practice. 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 3/10/25, the DOR in-serviced the Therapy Department on the facility's policy and procedure titled, "Resident Mobility and Range of Motion," with emphasis on staff identifying the resident's current ROM of his or her joints as part of the resident's assessment. The in-service also included completing joint mobility assessments on admission or re-admission and quarterly thereafter. The Medical Records Director will audit daily for 5 days weekly for 2 weeks and monthly thereafter to ensure that the therapy department is completing joint mobility assessments on a quarterly basis. On 3/13/25, the Director of Rehabilitation in-serviced RNs on the facility policy and procedure titled, "Splinting," with emphasis on preventing contractures or decreased tone and protecting joint alignment. The in-service also emphasized RNAs being responsible for applying the splint as ordered, documentation, and initialing on the schedule for splint application each time splint is applied, removed, or refused. The Medical Records Director will audit daily for five days weekly for two weeks and monthly thereafter to ensure that splint orders and RNA documentation are maintained, confirming residents are receiving their splints as ordered and that refusals are documented. How the facility plans to monitor its performance to ensure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting on the status of compliance regarding the therapy department completing quarterly joint mobility assessments and providing residents with splints as ordered for three months or until compliance is met.