Failure to Provide Range of Motion Services for Resident with Impairment
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including osteoarthritis, obesity, and lower extremity impairment, did not receive range of motion (ROM) services as required. The resident's Minimum Data Set (MDS) documented significant functional limitations and dependence on staff for activities of daily living, including self-care and mobility. Despite these documented needs, there were no physician orders for ROM or restorative nursing programs, and the care plan interventions focused only on assistance with daily activities, not on maintaining or improving ROM. Interviews with facility staff confirmed that the resident had not received any active or passive ROM services, and there was no documentation in the electronic medical record to indicate that such care was provided. The Director of Nursing acknowledged the absence of restorative CNA services and related charting, while the Director of Therapy stated the resident had only been verbally screened and had not received therapy services. The facility's policy required contacting the physician for treatment orders if none existed, but this was not done prior to the survey findings.