Failure to Document Restorative Nursing Services as Required
Penalty
Summary
The facility failed to document Restorative Nursing Aide (RNA) services provided to a resident with quadriplegia and cerebral palsy, as required by the facility's policy and procedure. The resident was dependent on staff for personal hygiene and bathing and had orders for passive range of motion (PROM) exercises to both upper and lower extremities, as well as the application of hand rolls, to be performed five times a week or as tolerated. Review of the Documentation Survey Report indicated that RNA services were not documented as provided on one specific day, and there was no documentation explaining the missed service. During interviews, the RNA responsible could not recall the events of the day in question and acknowledged that documentation should have been completed if services were not provided. The RNA later stated that, according to handwritten notes, all services had been completed but were not entered into the facility's charting system. The Director of Nursing confirmed that RNA services should be documented accurately to reflect care provided. The facility's policy required daily documentation of treatments and at least weekly documentation of progress, response to treatment, and functional status for residents in the Restorative Nursing Program.