Failure to Assess and Implement ROM Maintenance Program
Penalty
Summary
The facility failed to comprehensively assess and implement a nursing functional maintenance program to maintain or improve range of motion (ROM) for a resident with severely impaired cognition and functional limitations in all extremities. The resident's quarterly MDS indicated severe cognitive impairment and dependence on staff for all ADLs, with documented functional limitations in ROM, but no restorative nursing program was in place during the look-back period. The care plan did not address the resident's current ROM status or include specific interventions or exercises to prevent further decline. Medical records lacked an assessment of the resident's ROM status or any interventions to maintain ROM. Interviews with staff revealed that nursing assistants were not instructed to perform ROM activities with the resident, and nursing and therapy staff were unaware of any functional maintenance program or assessment for the resident. The therapy department stated they would assist if consulted, but such consultations were not routine. The assistant director of nursing confirmed that the resident had not been assessed for a maintenance program and that such programs were typically initiated only after therapy discharge or upon provider order, not as a preventive measure. The facility's policy required nursing personnel to be trained in rehabilitative care, including ROM exercises, but this was not implemented for the resident in question.