Failure to Maintain Resident's ADL Abilities Due to Lack of Therapy and Restorative Services
Penalty
Summary
The facility failed to ensure that a resident maintained the ability to perform activities of daily living (ADLs), including range of motion (ROM) and ambulation, without a documented medical reason for decline. The resident, who had diagnoses including heart failure, unspecified dementia, muscle weakness, and cognitive communication deficit, was discharged from hospice but did not receive therapy or restorative services for ROM or ambulation in the months following discharge. Medical record review showed no evidence of therapy screens or restorative programs in 2024 or 2025, except for a single therapy screen after the resident slid out of her wheelchair. The resident's care plan noted impaired mobility and encouraged participation in ADLs, but there was no documentation of ongoing therapy or maintenance programs to support ambulation or ROM. Observations and interviews revealed that the resident expressed a desire to walk again and reported not receiving recent therapy or ROM services. Staff interviews confirmed that the resident had not been screened by therapy since hospice discharge, and that quarterly therapy screens, which were standard practice, had not been completed. The Rehab Manager acknowledged the lack of recent ROM assessment and services, and certified nurse aides reported only seeing the resident self-transfer or take steps during toileting, with no independent ambulation observed in the room or hallway. The lack of regular therapy screening and absence of restorative or maintenance programs contributed to the resident's decline in ADL performance.