Failure to Provide and Document Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide and document restorative nursing assistant (RNA) services as ordered by the physician for a resident with limited range of motion (ROM) and mobility needs. The resident, who had moderate cognitive impairment but was able to understand and make decisions, was observed and interviewed, stating that she had not received ROM exercises as ordered. Medical record review confirmed missing documentation for passive range of motion (PROM) exercises for the left upper extremity and use of a hand splint, as well as for bilateral lower extremity exercises using the Omnicycle bike on multiple dates when these services were ordered to be provided. Interviews with RNA staff and the Director of Nursing (DON) verified that if RNA services were not documented, they were not performed, and that "not applicable" entries indicated the service was not provided. The facility's policies required that restorative nursing care be provided as needed and that documentation be objective, complete, and accurate. The DON confirmed the findings and acknowledged that the required RNA services were not provided or documented as ordered for the resident.