Failure to Implement Restorative Nursing Program for Resident with Limited ROM
Penalty
Summary
A resident with multiple medical conditions, including chronic pulmonary embolism, mild cognitive impairment, depression, history of intracranial hemorrhage, osteoporosis, acute respiratory failure, and type 2 diabetes mellitus with chronic kidney disease, was identified as having limited range of motion (ROM) in one upper extremity and both lower extremities. The resident required maximum assistance with dressing, hygiene, and all movement, and was wheelchair dependent. The facility's policy required that residents with limited ROM receive appropriate restorative nursing services to maintain or prevent further reduction in ROM. However, the resident's restorative plan, which included use of a Nu-step machine three times per week, was not implemented after therapy services ended. The resident reported that therapy had stopped and was unsure of the reason, while the Rehab Director confirmed the resident was no longer on the therapy caseload and was supposed to be on a restorative program instead. Interviews and record reviews revealed that the restorative order was not documented in the appropriate section of the resident's Kardex, and CNAs were unaware of the restorative program for the resident. The section of the Kardex designated for restorative programs was blank, and there was no evidence of CNA documentation or charting to show that the restorative plan was being carried out. The Director of Nursing acknowledged that the restorative order was in the wrong section and not being implemented, and the resident did not receive the maintenance program as intended.