Failure to Provide Ordered Restorative Therapy Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that a resident received restorative therapy as ordered by the physician. The resident, who had diagnoses including chronic respiratory failure with hypoxia, acute kidney failure, tracheostomy care, and malnutrition, was dependent for all activities of daily living and had impaired cognition. The care plan required passive range of motion exercises to be provided six to seven days a week, and the physician order specified passive range of motion to upper and lower extremities three to six times a week. However, documentation showed that the resident only received restorative therapy five times in a 30-day period. Interviews with facility staff confirmed that restorative therapy was not provided as scheduled due to staffing shortages, with restorative aides being reassigned to other duties. The facility's policy required regular screening and supervision of restorative nursing programs, but these were not followed as intended for the resident in question. This deficiency was identified during an investigation under a specific complaint number.