Failure to Provide Prescribed Restorative ROM Services
Penalty
Summary
A resident with multiple sclerosis, admitted in August 2022, was identified as requiring passive range of motion (ROM) exercises for both lower extremities to address impairments and prevent further decline. The resident's care plan, last revised in August 2025, included a restorative nursing program specifying bilateral knee and right hip passive ROM exercises. However, review of the resident's ROM Program Task tracking form and the restorative nursing services binder from early August to early September 2025 revealed no documentation that these restorative services were provided. The most recent Minimum Data Set (MDS) assessment also indicated that the resident did not receive passive ROM during the look-back period, despite being cognitively intact and having documented ROM impairment. Interviews with the resident and multiple staff members confirmed that the resident was not receiving the prescribed ROM exercises. The resident reported that staff no longer provided ROM exercises for their legs. Certified Nursing Assistants (CNAs) interviewed were either unaware of the resident's need for restorative services or confirmed they had not provided the exercises. The LPN Resident Care Manager acknowledged the resident's restorative program and stated that, following the absence of a designated restorative aide, CNAs were responsible for delivering these services, which were expected to be provided according to the care plan.