Failure to Provide Ordered Range of Motion (ROM) Services
Penalty
Summary
Nursing staff failed to provide necessary treatment and services to maintain or improve range of motion (ROM) for a resident with significant medical needs, including cerebral palsy, tracheostomy and gastrostomy dependence, severe contractures, and epilepsy. Physician orders and the resident's care plan specified that passive ROM exercises were to be performed on both upper extremities every AM shift and both lower extremities every night shift, as tolerated. However, a review of documentation revealed multiple instances where ROM activities were not completed or documented as required over several weeks. Certified Nursing Assistant (CNA) confirmed the missing documentation and acknowledged that ROM was not provided as ordered. The Director of Nursing (DON) and Administrator also verified that facility policy required restorative and supportive care, including ROM, to maintain joint mobility and prevent further deterioration. The DON stated that the policy was not followed and that nursing staff were expected to complete both the care and documentation as ordered.