Failure to Document Restorative Nursing Program for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for restorative therapy for one resident. The resident, who had diagnoses including osteoarthritis, dementia, and mobility abnormalities, was admitted with a care plan requiring one-person assistance for ambulation using a rolling walker. After discharge from physical therapy, the therapy summary recommended a restorative nursing program (RNP) to maintain the resident's current level of function and prevent decline, and indicated that the RNP had been developed and instructed to the interdisciplinary team. However, review of the clinical record showed no documented evidence that the RNP was being completed with staff. During an interview, the Assistant Director of Nursing confirmed that residents on the RNP program did not have a designated area for documentation when the RNP was completed.