Failure to Provide ROM Care for Resident
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) care for a resident who was admitted with a history of a condition affecting his left non-dominant side, resulting in atrophy. The resident was observed multiple times without the necessary extension and resting splints that were part of his care plan. The resident expressed that he was unable to put on the splints himself and that a Certified Nursing Assistant (CNA) who used to assist him no longer worked at the facility. The splints were found in a drawer in the resident's room, and he reported not having worn them for the past four months. The Unit Manager (UM) confirmed that the responsibility for placing the splints on residents lay with the nurses and CNAs. Despite documentation in the Electronic Health Record indicating that the splints were applied on specific dates, there was no evidence to verify that the resident had been wearing them. The Rehab Director and Occupational Therapist noted that the splints were necessary to prevent worsening of the resident's condition if not worn as ordered.
Plan Of Correction
1. The physician for resident #75 was notified on and new orders were given for a , evaluation for a spiit program for management. Evaluation was completed on . New orders were given by for a management program on. 2. On an audit was completed by Director of Nursing/designee to ensure residents with a current management program have an appropriate and physician order. Evaluations and clarification orders were received as necessary. 3. From to education was provided to the licensed nurses and CNAs by the Director of Nursing/designee on following physician orders for programs and ensuring there is appropriate documentation in the resident's electronic health record, including documentation of resident refusals. 4. An audit will be completed by Director of Nursing/designee weekly for four weeks and then monthly for two months to ensure residents with a current management program have on appropriate according to physician orders. The results of the audits will be reported to the Quality Assessment, Assurance, and Compliance Committee monthly for three months or until the committee has determined substantial compliance has been met.