Failure to Provide Ordered Restorative Nursing Program Due to Documentation System Change
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order to provide a Restorative Nursing Assistant (RNA) program for a resident with contractures in both hands and limited mobility. The resident reported not receiving exercises or being out of bed for some time. Review of the resident's Order Summary Report showed an active order for RNA staff to perform active assisted range of motion (AAROM) exercises to both lower extremities three times per week, once daily, as tolerated. However, the Restorative Nursing Assessment Log indicated that no RNA program was provided to the resident for an 11-day period, and the assigned RNA confirmed that she had not performed the exercises due to lack of access to the electronic health record system and the resident not being included in the printed log used for tracking RNA services. Further interviews revealed that a recent change in the facility's electronic documentation system resulted in the RNA program orders not being accessible or printed for staff, leading to the resident being missed for the entire month. The Director of Staff Development acknowledged the issue, stating that the transition to a new software system disrupted RNA access and that paper logs were being used temporarily. Facility policy required the RNA to carry out the restorative program according to the care plan and document daily, but this was not followed for the resident in question.