Failure to Maintain or Improve Range of Motion and Address Contractures
Penalty
Summary
A deficiency was identified when the facility failed to maintain or improve range of motion (ROM) and address contractures for a resident with Down syndrome and adult failure to thrive, as recommended by the restorative program. Observations showed the resident had contracted hands and limited finger movement, yet the care plan did not document any interventions or goals related to ROM, contractures, or a restorative program. The resident's Minimum Data Set (MDS) indicated limited ROM in the lower extremities, but no impairment in the upper extremities, and the care plan only referenced deficits in activities of daily living (ADLs) without addressing ROM needs. Physical therapy records documented that a restorative program for ROM, transfers, and bed mobility was established and staff were educated on these interventions. However, interviews with facility staff revealed that there was no formal restorative or functional maintenance program in place for the resident, and no documentation existed to show that such interventions were being provided. Staff stated that ROM and related interventions were expected to be completed by CNAs during ADLs, but there was no evidence in the electronic health record or care plan to confirm that these tasks were being performed.