Failure to Provide Range of Motion Care After Family Request
Penalty
Summary
A resident with diagnoses including neuromyelitis optica, diabetes, and encephalopathy was dependent on staff for activities of daily living such as dressing, eating, and oral hygiene. The resident's care plan noted a need for assistance with ADLs due to impaired mobility and weakness, but did not include specific interventions for range of motion (ROM) exercises. Documentation showed that the resident had been discharged from physical and occupational therapy several months prior, and no new therapy referral was made despite a significant change in condition and a family request for ROM therapy due to stiffness. Interviews with staff confirmed that ROM exercises would be documented if performed and that therapy referrals should be made following a change in condition or family request. The nurse manager and DON both acknowledged that a therapy referral should have been initiated after the family's request, and that ROM interventions should have been included in the care plan or Kardex. Facility policy required assessment of ROM and referral to therapy as appropriate, but these steps were not followed, resulting in a failure to provide necessary ROM care for the resident.