Failure to Implement Physician-Ordered ROM Intervention
Penalty
Summary
A resident with diagnoses including dementia, muscle weakness, and gait abnormalities was identified as having limited range of motion (ROM) in the right foot and was dependent on staff for personal hygiene and dressing. The clinical record showed that a physician ordered a molded ankle foot orthosis (MAFO) to be worn at all times on the right foot when the resident was out of bed. Despite this order, multiple observations over two days found the resident in a wheelchair without the MAFO brace applied. The Therapy Director confirmed that the resident had a contracture of the right foot and that the MAFO should have been in use during these observations. The facility failed to implement the prescribed intervention to prevent further decline or improve the resident's ROM, as evidenced by the absence of the MAFO brace during the observed periods.