Failure to Provide and Document Restorative Nursing Program for Resident
Penalty
Summary
A resident with diagnoses including acute respiratory failure, paraplegia, unspecified psychosis, asthma, and chronic hepatitis was evaluated by occupational therapy, which determined that occupational therapy was not required and referred the resident to the restorative nursing program. The resident's quarterly restorative assessment indicated that a restorative nursing program was recommended and should be continued, specifically for passive range of motion (ROM), active ROM, and bed mobility. The annual MDS assessment documented that restorative nursing programs were performed for at least 15 minutes a day for five days in the past week for these interventions. However, a review of the resident's medical record did not reveal any documentation of restorative nursing program minutes being provided for passive ROM, active ROM, or bed mobility. Additionally, there were no physician orders for a restorative program in the past year. The DON confirmed that there was no documentation of restorative nursing program minutes and that the restorative nursing programs for passive ROM, active ROM, and bed mobility were not being provided.