Failure to Provide Restorative Services and Splint/Brace Assistance
Penalty
Summary
The facility failed to ensure that residents consistently received restorative services and/or splint brace assistance to maintain or prevent declines in mobility and range of motion (ROM) for multiple residents. For one resident with a history of stroke and left-sided weakness, therapy services were discontinued without a referral to a restorative nursing program, despite recommendations for home ROM exercises. Staff interviews confirmed that the referral process was missed, and the resident was not followed up for restorative care after therapy ended, leaving them dependent on staff for mobility and dressing. Another resident with paraplegia and chronic pain was observed with a contracted left hand and reported no longer receiving restorative services or assistance with their hand splint. Care plan reviews showed that restorative services had been discontinued, despite prior therapy discharge recommendations for a restorative program and splint use. Staff interviews revealed that the resident was not referred to restorative nursing as recommended, and the resident experienced a decline in functional mobility, with staff unable to locate the necessary splint. A third resident with muscle wasting and a tracheostomy was observed with upper extremity contractures and reported that the restorative program was not being provided, despite wanting to participate. Therapy discharge summaries recommended a restorative ROM program with splint/brace, but there was no order or care plan for such a program. Staff confirmed that the referral for restorative services was missing, and the resident's needs were not met according to expectations.