Failure to Provide Range of Motion and Restorative Services for Resident with Contractures
Penalty
Summary
A resident with contractures in the left upper and lower extremities was observed over several days with her left arm and hand contracted to her chest and abdomen. The resident reported not having received any therapy or restorative services since admission. Record review confirmed that the resident was admitted with contractures and her care plan included a goal to remain free of complications related to contracture and immobility. However, there was no evidence in the medical record that a therapy screening or restorative program had been initiated for her. Interviews with facility staff revealed inconsistencies and lack of documentation regarding therapy screenings. The Director of Therapy stated that screenings were conducted on several dates, but no documentation could be provided. The only documented screening was after the resident experienced falls, and no restorative program had been initiated. The restorative nurse confirmed that the resident had not received any restorative services for splinting or range of motion since admission. This failure to assess and provide appropriate services for range of motion and contracture management led to the deficiency.