Failure to Provide and Document Restorative Nursing Care for Resident with Limited ROM
Penalty
Summary
The facility failed to provide and document restorative nursing care for a resident with limited range of motion (ROM) and mobility, as ordered by the physician and outlined in the resident's care plan. The resident, who had diagnoses including secondary parkinsonism, type 2 diabetes mellitus, and muscle wasting, was assessed as having severe joint mobility loss in both hips and knees, and was at risk for contracture development. Orders and care plans specified that the resident should receive passive range of motion (PROM) exercises to both upper and lower extremities and have bilateral knee splints applied for four hours, five times a week, or as tolerated. Observations on multiple dates revealed that the resident was not wearing the prescribed knee splints, and staff interviews confirmed that the splints were not consistently applied as ordered. One RNA admitted to forgetting to apply the splints on a specific day, and another stated that the splints were not reapplied after a shower due to a lunch break. Additionally, staff interviews indicated that documentation of the application of splints and provision of PROM exercises was not performed daily as required, but only once a week in progress notes. A review of the resident's documentation for the relevant period showed no evidence that the restorative nursing interventions were provided from 4/1/2025 to 4/8/2025 and 4/10/2025 to 4/13/2025. The Director of Nursing confirmed the lack of documentation and stated that if it was not documented, it was not done. The facility's policy required restorative nursing care to be provided as needed to promote optimal safety and independence, but this was not followed for the resident during the specified periods.