Failure to Provide Consistent Range of Motion Services
Penalty
Summary
A deficiency was identified when a resident with a physician-ordered range of motion (ROM) program did not consistently receive the prescribed services following discharge from physical therapy. The resident reported that after therapy ended, staff either did not perform the recommended exercises or did so inconsistently. Clinical records confirmed that the resident was to receive both active and passive ROM programs to the lower extremities, but documentation showed that these services were not provided from May 16 to May 31. This lapse was attributed to a communication issue between therapy and nursing, resulting in the ROM program not being initiated until June 1. Further review of documentation for June revealed that the resident did not receive the required active ROM exercises on multiple days throughout the month, despite being scheduled for daily sessions. The Director of Nursing acknowledged the communication breakdown and the resulting failure to implement the ROM program as recommended. The deficiency was based on the facility's failure to ensure that the resident received appropriate treatment and services to maintain or improve range of motion as required.
Plan Of Correction
The facility completed a review of resident #19's ROM/Mobility tasks in PointClickCare. Tasks were updated and staff implemented said tasks. No evidence or actual ill effects exist on any resident in our community due to lack of adherence to the requirements of increase/prevent decreases in ROM/mobility. A report was generated to indicate residents with range of motion or mobility issues, and those identified were reviewed individually. Any related issues were updated, and staff were instructed to implement said tasks. An education session was completed by the director of nursing or designee with clinical and therapy staff to ensure proper communication between nursing and therapy disciplines, documentation on Point of Care, and tasks being initiated on PointClickCare. A review of 10 records will be completed weekly for one month for any identified residents with ROM/Mobility tasks and bi-weekly for 3 months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, including an explanation of any identified variance infractions.