Failure to Provide and Document Range of Motion Care for Resident with Contractures
Penalty
Summary
A resident with diagnoses of rheumatoid arthritis, Parkinson's Syndrome, and Alzheimer's was observed to have contractures in both wrists and reported limited use of their hands, which prevented participation in activities. The resident's care plan identified limited mobility and contractures, with a goal to prevent further immobility complications and an intervention for daily gentle range of motion (ROM) exercises as tolerated. Despite these documented needs and interventions, there was no evidence in the Medication Administration Record, Treatment Administration Record, or nurse aide task sheets that ROM exercises were provided or documented for the resident. The Director of Nursing confirmed that ROM was not documented due to the absence of an official restorative program and stated that nurse aides were expected to perform ROM exercises during routine care without recording them. Additionally, the facility did not have an official policy for contracture care.