Failure to Provide and Document Restorative Therapy Services
Penalty
Summary
The facility failed to provide restorative therapy services as recommended for two residents with significant medical needs. One resident with paraplegia, who was cognitively intact, reported receiving restorative therapy infrequently due to staff shortages. There were no active therapy orders in the resident's record, and the Director of Physical Therapy was initially unaware of the resident's therapy status. Documentation provided indicated the resident was part of the Restorative Nursing Program (RNP), but there was no evidence of therapy orders or records of services provided. The Director of Nursing confirmed that the facility did not have a functioning RNP due to insufficient staffing, and acknowledged that documentation of restorative services was lacking, despite the expectation that such documentation should be maintained in the electronic medical record. A second resident, also cognitively intact and with a history of cerebral infarction and atrial fibrillation, reported inconsistent receipt of restorative therapy after being discharged from physical therapy due to insurance issues. The Director of Physical Therapy had referred this resident to restorative therapy, but the facility did not have an active restorative program in place. The only restorative aide, Staff C, was responsible for 29 residents but had not documented any restorative services provided, citing lack of access to a documentation kiosk and not keeping written records. The Director of Nursing confirmed that the facility previously had a restorative program but currently lacked the necessary staff to operate it effectively. Interviews with staff revealed that restorative therapy recommendations were being made and residents were identified for the program, but there was no systematic tracking or documentation of services rendered. The sole restorative aide selected therapy days based on her work schedule and attempted to see all assigned residents, but admitted it was difficult to provide adequate time to each due to workload. The lack of documentation and insufficient staffing led to the failure to provide and record restorative therapy as required for the residents.