Failure to Provide and Document Restorative Therapy Services for Resident with Declining Mobility
Penalty
Summary
The facility failed to ensure that restorative therapy services were implemented to prevent avoidable reduction of range of motion (ROM) for a resident with a history of peripheral vascular disease, high blood pressure, and atrial fibrillation. The resident reported not receiving any therapy since being moved to a different floor about a year prior, and stated that therapy was discontinued due to insurance coverage issues. Review of the resident's Minimum Data Set (MDS) assessments showed a decline in mobility and increased dependence on staff for transfers and bed mobility, but no significant change MDS was completed to reflect this change in status. The care plan documented resolved interventions for restorative nursing services, but there was no documentation in the progress notes regarding the implementation or resolution of these services. Interviews with staff revealed a lack of clarity regarding the resident's participation in restorative therapy and the process for reassessment and reapproach after removal from the program. The restorative nurse confirmed that the resident had refused the Restorative Nursing Program and was removed from it, with no current system in place to reassess or reapproach residents who had been discontinued from the program. The Director of Nursing Services acknowledged a performance improvement plan related to restorative nursing services, but it was not active and did not address reassessment of residents previously on the program.