Failure to Provide and Document Restorative Nursing Care for Range of Motion
Penalty
Summary
The facility failed to provide necessary restorative nursing care and services to maintain or improve range of motion (ROM) for two residents with significant mobility impairments. For one resident with functional quadriplegia, physician orders and care plans required active and passive ROM exercises to the upper and lower extremities five times per week. However, documentation revealed multiple days where these exercises were not recorded as completed, and both restorative nursing assistants (RNAs) could not confirm whether the care was provided or simply not documented. The transition from electronic to paper records contributed to missed or incomplete documentation, and weekly summaries were also missing for certain periods. The resident reported receiving exercises less frequently than ordered and was not informed when sessions were missed. Another resident with severe cognitive impairment and contractures was ordered to receive passive ROM exercises and have splints applied to the left hand, elbow, and knee for specified durations. Observations on several occasions found the resident in bed without the required splints, and staff confirmed the splints were not in use at those times. Documentation for the application of splints and provision of ROM exercises was incomplete, with missing staff initials on several days and no record of the actual hours the splints were worn, as required to assess tolerance. Staff acknowledged that only the minutes spent applying splints were documented, not the duration of wear. Interviews with staff and review of records confirmed that restorative nursing interventions were not consistently provided or documented as ordered for both residents. There was no evidence of resident refusal for the missed interventions, and staff attributed the lapses to documentation issues and oversight during a system transition. The lack of consistent care and documentation posed a risk for further decline in ROM and functional mobility for the affected residents.