Failure to Implement Functional Mobility Program After PT Discharge
Penalty
Summary
A deficiency occurred when facility staff failed to implement a functional mobility program for a resident with limited range of motion (ROM) and mobility needs, as recommended by Physical Therapy (PT) upon discharge from skilled services. The resident, who had diagnoses including Type II Diabetes with diabetic neuropathy, Myasthenia Gravis, and difficulty walking, was cognitively intact and had been receiving PT and Occupational Therapy. PT discharge documentation indicated that the resident was able to ambulate with a rollator and required Contact Guard or Stand By Assist, and that staff had been in-serviced on the resident's ambulation plan. The PT discharge summary recommended continued out-of-bed activity and ambulation with staff assistance to maintain the resident's current level of function. Despite these recommendations and documented staff education, the resident reported that staff had not walked with them since discharge from rehabilitation services. Observations and interviews confirmed that the resident remained in bed or in a wheelchair, used briefs instead of walking to the bathroom, and was not offered opportunities to ambulate with staff. Review of the resident's CNA Care Card and documentation revealed no updates or records indicating that staff were assisting the resident with walking or transfers as recommended by PT. Nursing progress notes also lacked evidence of any plan or offers to walk with the resident. Interviews with staff, including CNAs and rehabilitation personnel, confirmed that although in-service education was provided, the care plan and CNA Care Card were not updated to reflect the PT recommendations. The Director of Nursing acknowledged that the Care Card should have been updated to communicate the resident's ambulation needs to staff, but this was not done, resulting in the resident not receiving the necessary care and services to maintain or improve mobility and ROM.