Failure to Provide Appropriate ROM and Mobility Services
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to maintain or improve range of motion. The resident, who was previously able to walk 150 feet with supervision or minimal assistance and had no documented limitations, began experiencing an unsteady gait, shuffling, and difficulty lifting his right foot. Despite a request from the resident's wife for a physical therapy screen due to these mobility concerns, the initial therapy referral indicated no skilled therapy needs and no change in function. Subsequent assessments documented a decline in the resident's ability to perform activities of daily living, including increased assistance required for ambulation, toileting hygiene, and dressing. A therapy referral was eventually made for the resident's significant decline, and occupational therapy evaluated the resident, noting no further needs but referring to physical therapy for ambulation training. Physical therapy did not assess the resident until over a month later, after which a restorative ambulation program was recommended. However, the facility was unable to provide any documentation that such a restorative nursing program was implemented for the resident, despite physical therapy's recommendation and the resident's ongoing decline. Interviews with facility leadership confirmed both the delay in therapy services and the absence of evidence for the restorative program.