Failure to Resume Restorative Nursing Services for Resident with Limited Range of Motion
Penalty
Summary
A resident with a history of metabolic encephalopathy, generalized muscle weakness, and epilepsy was admitted and later readmitted to the facility with documented limitations in range of motion (ROM) in both upper and lower extremities. Assessments indicated moderate to severe ROM limitations, and the care plan specified the need for a Restorative Nursing Program (RNA) to maintain or prevent further decline in joint mobility. However, upon readmission, the physician's order for RNA exercises was discontinued and not reinstated, despite subsequent assessments and care plans continuing to indicate the need for such services. Observations and interviews with facility staff, including a CNA, LVN, RN Supervisor, and the Director of Rehabilitation, confirmed that the resident had not received RNA services for several months following readmission. Staff were unable to locate active orders for RNA in the resident's records, and several staff members acknowledged that the resident should have been receiving these services due to their limited ROM. The Director of Rehabilitation was unaware that the resident had returned to the facility without an active RNA order, and the DON could not explain why the RNA program was not resumed upon readmission. Facility policy and procedures required that residents with limited ROM receive restorative nursing care and interventions to prevent further decline. Despite these policies and the resident's documented needs, the facility failed to ensure the continuation of RNA services as indicated in the care plan and assessments. This lapse was identified through record review, staff interviews, and direct observation, demonstrating a failure to provide appropriate care to maintain or improve the resident's ROM.