Failure to Follow ROM and Fall Prevention Orders
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to prevent further decline in ROM. Specifically, the facility did not consistently follow physician's orders for the application of a left ankle-foot orthosis (AFO) and bilateral elbow splints for a resident with contractures in both upper and lower extremities. Documentation showed inconsistent entries regarding the application and removal of these devices, with several dates lacking clear records of whether the devices were applied or removed. Additionally, there was no documented evidence that skin assessments were performed when the devices were applied, despite this being an intervention listed in the care plan and required by facility policy. Interviews with restorative nursing assistants (RNAs) and registered nurses (RNs) confirmed that the required documentation was missing or inaccurate. The RNAs stated that skin checks were performed before and after device application, but acknowledged that these assessments were not documented in the resident's medical record. The RNs also verified the absence of documentation for both the timing of device application/removal and the required skin assessments. The director of nursing (DON) was informed of and verified these findings. Another deficiency was identified related to accident prevention. The facility failed to implement physician-ordered floor mats on both sides of a resident's bed, which was a safety intervention intended to reduce the risk of injury from falls. This omission was contrary to the facility's falls prevention policy, which requires individualized interventions based on assessed fall risk. The failure to provide the ordered safety equipment placed the resident at high risk for serious injury from a fall.
Plan Of Correction
2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents with splints were potentially affected by this deficient practice. DON, ADON, and Unit managers conducted an audit on all residents receiving splints, braces, and ROM devices and found no other issues noted. On 8/5/2025, DON in-serviced all licensed nurses about facility policy and procedure of splint, braces, and ROM devices assessment and to add monitoring for skin integrity at least every 2 hours and as needed. On 8/6/2025-8/8/2025, DSD in-serviced all CNA and RNA about facility policy and procedure of application of ROM devices, splint, and braces to report immediately to licensed nurses if skin breakdown was noted beneath the devices. Plan of care was updated for all residents with medical devices application for splinting, braces, and ROM devices to include monitoring of skin breakdown at least every 2 hours and as needed when devices were applied on the resident. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. All new medical devices orders will be reviewed during clinical meetings to make sure RNA is following the treatment plan and monitoring for skin integrity was included in the plan of care. IDT will review monthly and as needed all residents with medical devices application and update the plan of care. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 --- F689 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 4 was identified as affected by this concern. On 7/21/25, the Director of Nursing (DON) or designee reviewed the use of floor mats for the resident with the interdisciplinary team (IDT). After evaluation, it was determined that floor mats were no longer indicated. The recommendation to discontinue use was communicated to the physician, and the order was discontinued. The resident's care plan was updated accordingly. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All fall risk residents using floor mats were considered potentially impacted. On 8/4/2025, DON and unit manager reviewed all residents with floor mat orders and found no other issues. On 8/4/2025, the DON and designee created a list of all residents using floor mats. The IDT reviewed each case to determine ongoing need. For residents where use was no longer clinically indicated, recommendations were made to discontinue use, and care plans were updated to reflect current interventions. On 8/5/2025-8/8/2025, DON in-serviced all licensed nurses about facility policy and procedure for placing floor mats for residents at risk for fall, in particular assessing residents who are no longer on fall risks and have orders for floor mats to discontinue the devices as they are potentially an accidental hazard. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The DON or designee will oversee this process. Unit managers and designee will conduct routine audits to ensure appropriate placement and condition of mats, accurate documentation in the care plan, and use in accordance with current physician orders and clinical justification.