Failure to Provide Ordered Range of Motion Care for Resident with Contracture
Penalty
Summary
The facility failed to consistently implement physician-ordered range of motion (ROM) care for a resident with a contracture in the left hand. The resident, who had severe cognitive impairment and functional limitations in both upper and lower extremities, had a physician's order and care plan directing staff to place a rolled washcloth in the contracted left hand every shift to prevent further deterioration. Despite this, multiple observations over consecutive days showed the resident lying in bed without the required facecloth in the left hand. Interviews with staff, including a CNA and a nurse, confirmed that the facecloth was not in place as ordered, and there was no documented rationale in the medical record for this omission. The Treatment Administration Record (TAR) indicated that the intervention was signed off as completed every shift, despite the facecloth not being present during surveyor observations. The Director of Nursing acknowledged that the facecloth should have been in place per the physician's order and that any deviation should have been documented.