Failure to Maintain Resident Mobility Program
Penalty
Summary
A deficiency occurred when a resident with limited mobility, who had diagnoses including polyneuropathy, unilateral primary osteoarthritis of the left knee, and major depressive disorder, did not receive appropriate services to maintain or improve mobility. The resident had previously been on a walking program as recommended by therapy, which involved ambulation with assistance and the use of a walker and wheelchair follow for up to 20 feet, twice daily. Documentation showed the resident participated in the program on several occasions before it was discontinued. There was no documented medical reason or rationale for discontinuing the walking program, and the resident expressed frustration about not being able to continue walking, stating a desire to walk and concern about losing mobility. Interviews with facility staff, including a CNA, LPN, PTA, unit manager, and DON, revealed a lack of awareness or documentation regarding the reason for discontinuing the walking program. The facility's policy required communication and documentation of therapy recommendations and restorative programs, but there was no evidence that the discontinuation was communicated or justified. The absence of documentation and follow-through resulted in the resident not receiving the restorative care necessary to maintain or improve mobility, contrary to facility policy and the resident's expressed wishes.