Failure to Maintain Resident's Range of Motion and Functional Abilities
Penalty
Summary
The facility failed to ensure that a resident maintained their range of motion (ROM) to promote their highest practicable level of independence. The resident, admitted with diagnoses including absence of left leg below the knee, chronic pain, and type 2 diabetes mellitus, was cognitively intact and required staff assistance for bed mobility and transfers. The resident was noted to have impaired ROM in one upper extremity and both lower extremities, but their care plan did not include any focus area or interventions related to impaired ROM. The resident reported progressive loss of hand function, specifically curling of fingers and inability to straighten them, which affected their ability to feed themselves and reposition in bed—tasks they previously could perform. Observations confirmed the resident's difficulty in grasping utensils and repositioning independently, requiring increased staff assistance. Staff interviews corroborated the resident's decline in upper extremity function and increased dependence. The Director of Rehab acknowledged that a therapy screen or evaluation was not completed as required, and was unaware of the resident's decline in hand function and upper extremity strength. This lack of assessment and intervention contributed to the resident's continued decline in ROM and functional abilities.