Failure to Provide Individualized Restorative Program for Limited Range of Motion
Penalty
Summary
A resident with a history of acute and chronic respiratory failure, congestive heart failure, depression, and hemiplegia/hemiparesis following cerebrovascular disease was admitted to the facility and exhibited limited mobility on one side, affecting both upper and lower extremities. Multiple quarterly and significant change MDS assessments documented this limited mobility, yet the resident did not receive physical therapy, occupational therapy, range of motion (ROM) exercises, restorative services, or splint/brace assistance. Physician progress notes indicated the presence of a right-hand contracture, but there was no evidence in the comprehensive care plan or physician orders addressing limited ROM or contractures. Therapy documentation over an extended period showed no evaluation, screening, or intervention for the resident's limited mobility or contracture. During interviews and observations, the resident demonstrated an inability to open her right hand and confirmed she had not received therapy, splints, or any treatment to prevent worsening of her condition. The Director of Therapy Services verified that the resident had not been screened or evaluated for her limited mobility or contracture during the review period, except for an initial screening where the resident declined services. The Director also confirmed that, following a refusal, residents should be re-screened quarterly, which did not occur in this case.