Failure to Ensure Consistent Range of Motion Interventions and Therapy Attendance
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and significant physical limitations consistently attended scheduled therapy gym sessions as ordered. Documentation showed that the resident was marked as 'not available' for 11 out of 13 scheduled sessions, with no documented reasons for most absences. Staff interviews revealed inconsistent communication and documentation practices regarding the resident's attendance and reasons for missed sessions, despite care plan interventions specifying the need for staff to escort the resident to the gym and provide transportation. Additionally, the facility did not implement or care plan occupational therapy recommendations for another resident assessed as at risk for bilateral hand contractures and impaired skin due to clenching fists. Occupational therapy notes indicated the resident would benefit from holding an object during the day and participating in active assisted and passive range of motion programs. However, these interventions were not included in the resident's care plan or communicated to nursing staff, and observations confirmed the resident was not provided with recommended objects to hold or enrolled in a hand range of motion program. Both deficiencies were identified through a combination of record review, staff interviews, and direct observation. The lack of documentation and follow-through on therapy recommendations and scheduled interventions resulted in residents not receiving appropriate care to maintain or improve their range of motion and mobility, as required by their care plans and therapy orders.