Failure to Provide and Accurately Document Range of Motion Services
Penalty
Summary
The facility failed to ensure that three residents with limited range of motion (ROM) and mobility impairments received appropriate treatment and services as ordered by their physicians and in accordance with facility policy. Each of the residents had significant medical conditions, including hemiplegia, contractures, encephalopathy, Parkinsonism, epilepsy, muscle weakness, and abnormal posture, and were totally dependent on staff for activities of daily living. Physician orders for these residents included daily or five times weekly passive range of motion (PROM) exercises, application of splints, and use of handrolls, all intended to maintain or improve their ROM and prevent further decline. Record reviews revealed that these residents did not consistently receive the ordered restorative nursing assistant (RNA) treatments during a specified period. Specifically, documentation showed that from 5/15/2025 to 5/19/2025, the residents did not receive the full complement of RNA treatments as prescribed. Additionally, weekly summary notes for RNA treatments were documented in advance, rather than reflecting the actual care provided during the week. This practice was confirmed by interviews with the RNA, who stated that she completed the weekly summaries ahead of time, and by the DON, who acknowledged that documentation should not be completed in advance and must accurately reflect the care delivered. The facility's policies on Resident Mobility and Range of Motion, as well as Charting and Documentation, require that residents with limited ROM receive appropriate interventions and that documentation be objective, complete, and accurate. The failure to provide the ordered treatments and to document care accurately constituted a deficiency, as it did not meet the facility's own standards or professional practice requirements.