Failure to Develop and Implement Comprehensive Care Plans for Restorative Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents requiring restorative therapy and range of motion interventions. For one resident with hemiplegia and hemiparesis following cerebrovascular disease, physician orders indicated the need for restorative nursing therapy (RNP) for upper extremity range of motion exercises, but no corresponding care plan was developed. For another resident, physician orders included RNP for both lower extremity assistive range of motion (AROM) exercises, right upper extremity T-Bar orthosis/splint application for contracture management, and active assistive range of motion (AAROM) for both upper extremities. Despite these orders and documented functional limitations in range of motion, there was no person-centered care plan addressing these needs. Facility policy requires that individualized care plans with measurable objectives and timetables be developed for each resident to address their medical, nursing, mental, and psychological needs. The policies also specify that rehabilitative nursing care should be reinforced through the care plan and performed daily for residents requiring such services. The lack of care plans for the identified residents represents a failure to comply with these requirements, as observed through clinical record review and direct observation.