Failure to Implement and Document Ordered Restorative ROM Program
Penalty
Summary
The facility failed to implement and document an ordered restorative program for a resident with reduced mobility and decreased strength in both upper and lower extremities. The resident had a physician's order for a Level 2 restorative ADL/hygiene and range of motion (ROM) program, and the care plan specified the need for restorative ROM interventions. Despite this, there was no documentation of restorative services being provided for the last 30 days. Interviews with the resident, restorative aide, and the restorative director confirmed that the resident had not been consistently seen for restorative care, with staff citing the resident's preference for spending time outside and lack of set scheduling as reasons. The restorative director also admitted to not ensuring proper documentation or oversight of the program. The facility's own policy required daily review and documentation of restorative services, including time spent, resident tolerance, and reasons for missed sessions. However, these requirements were not met, as evidenced by the absence of documentation and staff acknowledgment of lapses in both service delivery and record-keeping. The resident expressed awareness of the missed services and a desire to participate in the restorative program, further confirming the deficiency in care.