Failure to Provide Range of Motion Interventions for Resident with Limited Mobility
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including Multiple Sclerosis, aphasia, and anoxic brain damage, was not provided with appropriate treatment and services to maintain or improve range of motion (ROM) or to prevent further decline. The resident was assessed as having limited ROM in one upper extremity and both lower extremities, as documented in the Minimum Data Set (MDS). Despite this assessment, there was no care plan in place addressing ROM, and no interventions or exercises were observed during care to address the resident's limitations. The facility's policy requires that interventions, exercises, and therapy be provided based on comprehensive assessment to maintain or improve ROM, and that these interventions be documented in the resident's care plan. However, a review of the resident's care plans revealed that none included interventions for ROM. The Kardex and other care documentation also lacked any mention of ROM exercises or related care. Interviews with facility staff, including the Rehab Director, MDS Coordinator, and Unit Manager, confirmed that the resident was not on a therapy or restorative program for ROM, and that staff relied on therapy referrals only if a decline in activities of daily living (ADLs) was observed. Direct observation of care provided to the resident showed that Certified Nursing Assistants did not perform any ROM exercises during routine care, and staff indicated that such exercises were believed to be the responsibility of therapy. The lack of a restorative program and absence of a care plan or documented interventions for ROM resulted in the resident not receiving appropriate services to prevent further decline in ROM, as required by facility policy and professional standards.