Failure to Provide Timely Equipment for ROM Maintenance
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary equipment to maintain range of motion (ROM) for a resident with limited mobility. The resident, who had a history of cerebral infarction resulting in right-sided weakness and was non-ambulatory, was assessed as needing an Ankle Foot Orthosis (AFO) to participate in an ambulation restorative program. Although an AFO was ordered in January, the referral lacked a provider signature and supporting documentation, leading to delays in processing. The resident was observed without the AFO several months later and reported decreased ROM after physical therapy services ended. Staff interviews confirmed that the resident was unable to ambulate without the AFO and only participated in group therapy using a wheelchair while waiting for the device. Further review revealed that the prosthetics and orthotics clinic denied the initial referral due to incomplete documentation, and additional paperwork was required. Staff acknowledged that the referral process and follow-up with outpatient providers were not conducted in a timely manner, resulting in a significant delay in the delivery of the AFO. This delay prevented the resident from starting the prescribed ambulation restorative program and maintaining or improving ROM as care planned.