Inaccurate Joint Mobility Assessment Due to Lack of Hands-On Evaluation
Penalty
Summary
The facility failed to accurately conduct a Joint Mobility Assessment (JMA) for a resident with multiple diagnoses, including dementia, type 2 diabetes, osteoporosis, osteoarthritis, and contracture. The resident was admitted with severe cognitive impairment and required substantial to maximal assistance with most activities of daily living. The JMA, dated 5/27/2025, indicated the resident had minimal to severe loss of lower extremity passive range of motion (PROM) and was at risk for contracture development. The assessment recommended a physical therapy evaluation and RNA services for PROM of both upper extremities. During interviews and record reviews, it was revealed that the physical therapist performed the JMA through observation and interviews with CNAs, without physically touching or moving the resident to assess PROM. The physical therapist confirmed that PROM was not performed during the assessment, and acknowledged that joint integrity could not be determined by observation alone. The Director of Rehab stated that PROM must be performed during a JMA to accurately assess joint condition, and that failing to do so results in an inaccurate assessment. The Director of Nursing also confirmed that inaccurate JMAs could result in residents not receiving necessary care. Facility policy required all services and changes in resident condition to be documented objectively, completely, and accurately in the medical record.