Failure to Provide and Accurately Document Restorative Ambulation Services
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned for a resident with decreased mobility and fatigue. The resident, who was cognitively intact and had a history of malignant neoplasm of the lung, was discharged from physical therapy with recommendations for a restorative ambulation program. The care plan specified that the resident should ambulate 50 feet with a rollator walker and the assistance of one caregiver, with interventions including proper footwear, instruction on device use, and wheelchair follow-along as recommended by therapy. Despite these documented interventions, the resident reported that after physical therapy services ended, no staff provided restorative ambulation services for over a month. Clinical records indicated that the resident received the intervention on multiple occasions, but during interviews, both the resident and the nurse aide responsible for the documentation confirmed that the ambulation program was not implemented as recorded. The DON acknowledged that the facility did not provide the planned restorative nursing services and that documentation was inaccurate.