Failure to Implement Interventions to Prevent Decline in Range of Motion
Penalty
Summary
Facility staff failed to implement interventions to prevent further decrease in range of motion (ROM) for a resident with multiple medical diagnoses, including pain, type 2 diabetes mellitus, heart failure, and major depressive disorder. The resident was admitted with these conditions and was identified as having limited mobility. Despite the facility's policy to provide maintenance and restorative programs to assist residents in achieving and maintaining the highest practicable outcome, there was no evidence in the resident's records of any restorative nursing program or interventions aimed at maintaining or improving ROM. Therapy screenings indicated that the resident would benefit from skilled services due to lack of mobility, but the resident refused out-of-bed activity and was only monitored and screened as needed. Observations revealed decreased ROM and nodules in the resident's left hand, and both the resident and the DON confirmed that no interventions were in place to prevent further decline in ROM. The comprehensive care plan and electronic health record lacked documentation of any such interventions.