Failure to Provide Prescribed ROM Exercises Due to Staffing Issues
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction, hemiparesis affecting the left side, muscle weakness, and severely impaired cognition did not receive prescribed range of motion (ROM) exercises as documented in their care plan. The care plan specified that nursing and restorative aides were to perform active ROM to the resident's bilateral lower extremities for 20 minutes, and staff were to observe and report any immobility or contracture formation. However, review of the resident's electronic medical record (EMR) showed no documentation that ROM exercises were performed, nor were there any recorded refusals by the resident. Interviews with facility staff revealed that the restorative aide, who was responsible for carrying out these exercises, had been reassigned to regular CNA duties due to understaffing and was unable to perform restorative duties during that period. The facility's restorative nursing policy required proactive identification, care planning, and monitoring of residents' needs, as well as training for nursing assistants in restorative techniques. Despite these requirements, the resident did not receive the necessary ROM interventions, resulting in a failure to provide appropriate care to maintain or improve mobility and prevent contractures.