Failure to Provide and Document Range of Motion Services
Penalty
Summary
A resident with diagnoses including Parkinson's disease, anemia, slow transit constipation, and osteoarthritis was identified as having limited range of motion (ROM) in both upper and lower extremities. The resident's care plan specified an active assisted ROM (AAROM) program, with a goal of performing one set of five repetitions to all extremities with limited staff assistance one to two times daily. However, there was no documentation in the electronic medical record (EMR) that the ROM program was being implemented. The restorative nurse confirmed that the last restorative assessment was completed several months prior, and although recommendations for active ROM and bed mobility were made, the resident was not included on the restorative list and had no program in place to guide staff on exercises or frequency. The resident also reported not receiving restorative assistance from staff, and the facility's policy required regular screening and implementation of restorative nursing programs.