Failure to Provide Restorative Care and Follow Therapy Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate restorative care and follow therapy recommendations for a resident with limited range of motion (ROM) and mobility issues. The resident, who had a history of arthritis, muscle weakness, and a right above-the-knee amputation with a prosthesis, was identified as needing ongoing restorative nursing programs (RNP) and therapy interventions to maintain or improve functional status. Despite multiple therapy evaluations and clear recommendations for restorative ambulation and ROM programs, documentation revealed that the resident did not receive restorative exercises or activities for extended periods, as indicated by the absence of restorative program documentation in the electronic health record and Minimum Data Set (MDS) assessments showing zero days of RNP during several look-back periods. Interviews with staff and the resident confirmed that restorative activities were not consistently provided. The resident reported not receiving any exercise program or ambulation assistance after being discharged from therapy services, stating that staff left him alone and he was on his own to perform exercises. Staff interviews revealed confusion and lack of clarity regarding responsibility for restorative care, with restorative duties assigned to staff who were also tasked with other responsibilities such as medication administration and transportation, making it difficult to consistently implement restorative programs. Staff also indicated that the restorative program had not been active for some time and that there was uncertainty about documentation and care plan updates related to restorative services. Policy review showed that the facility's restorative care policy required individualized restorative services based on assessment and care planning, with all employees responsible for providing restorative care. However, the lack of implementation and documentation of restorative activities for the resident, despite therapy recommendations and care plan directives, led to a failure in maintaining or improving the resident's ROM and mobility as required.