Failure to Consistently Implement Restorative Ambulation Program
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned to maintain mobility for a resident with a history of obstructive hydrocephalus, anxiety, and depression. The resident, who was severely cognitively impaired and non-ambulatory upon admission, received physical therapy and was discharged with the ability to ambulate 25 feet with contact guard assistance. The discharge summary recommended continued ambulation with a rolling walker for short distances, and a care plan was developed to support walking in the resident's room with staff assistance. However, documentation showed that the resident participated in the ambulation program on only four out of eleven days, with reasons for missed sessions including refusal, deferred due to condition, and unavailability. There was no evidence that licensed staff were aware of or evaluated the resident's refusals or missed ambulation sessions at the time they occurred. The Assistant Director of Nursing was unable to provide documentation that the restorative ambulation program was implemented as planned or that missed sessions were addressed to ensure the resident's ambulation goals were met.