Failure to Provide and Accurately Document Restorative Nursing Services
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned to maintain or improve mobility for a resident diagnosed with inflammatory polyarthropathy. According to the resident's care plan, a restorative nursing walking program was initiated, requiring staff to assist the resident in walking with a rollator walker for distances up to 350 feet or as tolerated. Despite this plan, the resident reported that she had only walked once in the past month and was not regularly asked to participate in the walking program, contrary to the documented interventions. Clinical record review showed that the ambulation task was marked as completed multiple times, but the resident denied receiving the service on those occasions. Further investigation revealed that a nurse aide admitted to documenting the ambulation task as completed before actually performing it, intending to provide the service later. The facility's policy requires ongoing monitoring and accurate documentation of restorative nursing programs, but there was a discrepancy between the documentation and the resident's account. The Nursing Home Administrator confirmed that staff should not document care tasks as completed if they have not occurred and was unable to explain the inconsistency between the records and the resident's statements.