Failure to Provide and Document Restorative ROM Services as Care Planned
Penalty
Summary
The facility failed to provide range of motion (ROM) exercises as care planned for a resident with multiple sclerosis and impaired mobility. According to therapy recommendations and the resident's care plan, the resident was to receive ROM exercises to both upper and lower extremities three times per week. However, documentation showed that the exercises were only offered one to two times per week, and in some weeks, not at all. The resident's care plan and therapy screening indicated the importance of these exercises to maintain mobility, but the facility's records did not reflect consistent implementation of the program. Interviews with staff revealed that the trained medication aide responsible for restorative nursing did not consistently document refusals or unavailability, and the registered nurse coordinating the program confirmed that exercises should be offered three times weekly with proper documentation of refusals. The resident reported that staff rarely offered the exercises and did not attempt to return at a later time if she initially refused. Additionally, the facility was unable to provide a policy for restorative nursing when requested.