Failure to Provide Ordered Range of Motion and Brace Application
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decline in range of motion for a resident with significant physical and cognitive impairments. The resident, who had a history of hemiplegia, hemiparesis, and aphasia, was dependent on staff for activities of daily living and had documented functional limitations in the upper and lower extremities on one side. The care plan and physician's orders specified that the resident should receive passive range of motion (PROM) exercises and application of a brace to the affected limb, with specific instructions for timing and monitoring. However, observations revealed that the resident did not have the prescribed device in place, and staff interviews indicated a lack of awareness or implementation of the required interventions. Review of documentation, including the Treatment Administration Record (TAR) and CNA Kardex, showed no evidence that PROM or brace application had been performed as ordered. Staff interviews confirmed that the interventions were not being carried out, and the Director of Nursing verified the absence of documentation for these treatments. As a result, the facility did not meet the licensure requirement to provide adequate and appropriate health care and services consistent with the resident's care plan and physician's orders.
Plan Of Correction
F688 Increase/Prevent Decrease in ROM/Mobility (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident # 31 was assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On , the order was clarified with MD to indicate donning and doffing of , as well as performing PROM. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On Audit was completed by Director of Nursing/designee on residents who had orders for /braces to ensure order indicated donning and doffing equipment. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By , Current Nurses and staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and Prevention of decrease in ROM/Mobility by the DON/Designee. Newly hired licensed nurses/ , Staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and prevention of decrease in ROM/Mobility by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents with physician orders for a /brace 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that the physician order includes documentation of donning and doffing /brace. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.