Inaccurate Documentation of Restorative Nursing Services
Penalty
Summary
The facility failed to ensure that restorative nursing aide (RNA) records accurately reflected the provision of passive range of motion (PROM) to both legs for a resident with significant mobility limitations, as ordered by the physician. The resident, admitted with diagnoses including neoplasm of the meninges, nontraumatic intracerebral hemorrhage, lack of coordination, muscle weakness, foot drop in both feet, and reduced mobility, had a physician's order for active assistive range of motion (AAROM) to both arms and PROM to both legs. However, documentation from 4/22/2025 to 5/5/2025 indicated that the RNA provided AAROM to both arms and the right leg, and PROM only to the left leg, which did not align with the physician's order. Observations and interviews confirmed that the RNA was performing AAROM on the right leg and PROM on the left leg, rather than providing PROM to both legs as ordered. The resident was able to participate in AAROM for the right leg with some assistance, but the documentation and care provided did not match the original physician's order. The discrepancy was identified during a review of the resident's medical records and through direct observation of the RNA session. Further review with the Director of Medical Records (DMR) confirmed that the documentation did not accurately reflect the care ordered by the physician. The DMR acknowledged that the RNA services documented from 4/22/2025 to 5/5/2025 were inconsistent with the physician's order and that the facility did not have a policy or procedure in place to ensure medical record accuracy. This resulted in inaccurate provision and recording of care in the resident's medical records.