Failure to Provide Restorative Services for Resident with Limited Mobility
Penalty
Summary
A deficiency was identified when a resident with a history of pleural effusion, who had previously received physical therapy, was not offered restorative services to maintain or improve range of motion (ROM) after discharge from therapy. The resident expressed interest in continuing physical therapy or restorative services during a care conference, and a progress note indicated the resident would be a good fit for a restorative program. Despite this, there was no evidence in the clinical record that restorative services were provided. The resident reported not receiving physical therapy for over two months and not being offered ROM exercises, even though they wished to participate in restorative services. Staff interviews revealed confusion and lack of follow-through regarding the resident's enrollment in restorative services. One CNA believed the resident was receiving restorative care but had not observed participation, while another confirmed the resident was not on the restorative list. The restorative aide stated the resident was discussed for possible inclusion but was not added due to a full caseload. The RN case manager was unsure why the resident was not enrolled after expressing interest, and the regional administrator acknowledged the expectation that residents who express interest should be offered restorative services.