Failure to Implement Interventions for Declining Range of Motion
Penalty
Summary
A resident with a history of non-traumatic subarachnoid hemorrhage, torticollis, and left hemiplegia was identified as having limited range of motion (ROM) in the left upper extremity. The resident was dependent on staff for personal hygiene and dressing, and initial occupational therapy (OT) assessments did not note functional limitations due to contracture. However, a subsequent OT evaluation documented a functional limitation due to contracture, and observations over several days confirmed that the resident's left hand and wrist were slightly contracted. The resident reported that her hand had worsened and she was experiencing increased difficulty moving it. Despite the documented decline in ROM and the resident's own report of worsening condition, there were no interventions implemented to prevent further decline or to improve ROM. The OT discharge summary did not include any recommendations or restorative nursing program, and staff confirmed that no interventions had been put in place following the decline. This failure to implement appropriate care and interventions led to the deficiency cited under 28 Pa. Code 211.12(d)(1)(5) Nursing services.