Failure to Maintain Resident's Ambulation and ADL Abilities Post-Therapy
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received services to maintain their abilities in activities of daily living (ADL). The resident had a history of right shoulder dislocation, muscle weakness, and unsteady gait, and was documented as having intact cognition. Assessments indicated the resident was dependent on staff for most ADLs but was independent with wheelchair mobility. Physical therapy records showed the resident participated in gait training and was able to ambulate short distances with assistance, with a goal to increase ambulation distance. However, after discharge from therapy, there was no evidence in the electronic health record of a formal or informal walking or restorative program to maintain the resident's ambulation abilities. Observations and interviews revealed that the resident expressed a desire to continue therapy and questioned why it had been discontinued. Staff interviews indicated confusion regarding who was responsible for restorative care and ambulation, with some staff unaware of the resident's ambulation abilities or care plan requirements. The care plan lacked specific instructions for staff to ambulate the resident, and staff reported only performing such activities if directed by the care plan. Therapy staff stated that recommendations for maintaining function were typically communicated to nursing, but in this case, nursing staff reported not receiving any such recommendations after therapy discharge. The facility's policy required providing care and services to maintain or improve residents' ADL abilities, including mobility and ambulation, in accordance with assessed needs and preferences. Despite this, the resident did not receive ongoing support to maintain ambulation after therapy ended, and there was a lack of communication and documentation regarding the continuation of restorative activities. This resulted in the resident not receiving necessary services to maintain functional abilities as required.