Failure to Provide and Document Restorative Nursing Care for Range of Motion
Penalty
Summary
The facility failed to provide restorative nursing care for range of motion (ROM) exercises for two residents with limited ROM. For one resident with diagnoses including dysphagia, vascular dementia, and contractures of the hands, neck, and legs, the care plan and Kardex specified restorative passive ROM for both upper and lower extremities during morning and evening care. However, there was no documentation in the clinical record to indicate that these restorative nursing services were being provided. The Director of Nursing (DON) confirmed that a system glitch prevented the task from being added for staff to complete, and no documentation could be provided to show that the care was delivered prior to a certain date. The DON stated that staff were expected to perform the care, but acknowledged it was not documented anywhere. For another resident with dementia, chronic kidney disease, and depression, an occupational therapy note recommended the use of palm guards and both active and passive ROM as part of a restorative nursing program. The nursing tasks included encouraging the use of palm guards and providing hand hygiene, but there was no documentation to confirm these interventions were carried out. The DON explained that the task was entered incorrectly, resulting in a lack of documentation, and stated that restorative nursing programs should be implemented and documented.