Failure to Provide and Document Restorative ROM Services
Penalty
Summary
The facility failed to consistently provide restorative services to maintain or improve range of motion (ROM) for two residents with documented ROM impairments. For one resident with cerebral palsy and contractures in the upper and lower extremities, care plans indicated the need for interventions such as maintaining body alignment, use of braces or splints, and monitoring by occupational and physical therapy. Despite these interventions being documented, observations and interviews revealed that the resident was not on a restorative program, did not use splints, and was not receiving regular ROM exercises. Multiple staff interviews confirmed the absence of a restorative program and lack of documentation or implementation of ROM interventions for this resident. Another resident with an upper extremity ROM impairment was care planned to receive a restorative nursing program 6-7 days a week. However, review of facility documentation showed that the program was only documented as provided on one day over a month-long period. The resident reported that no one was performing exercises with them, and staff interviews confirmed that there was no documentation of the restorative program being carried out. It was further revealed that an error in the electronic health record system prevented prompts for documentation, resulting in a lack of recorded services for approximately a month. Staff interviews, including those with the restorative aide, MDS coordinator, and DON, consistently indicated an expectation that residents with contractures or ROM impairments should be on a restorative program with appropriate documentation. The lack of consistent implementation and documentation of restorative services for these residents constituted a failure to meet the facility's policy and regulatory requirements for maintaining or improving residents' ROM.