Failure to Provide Ordered PROM Therapy to Lower Extremities
Penalty
Summary
A deficiency occurred when a resident with a history of contracture deformity and complete dependence on staff for all activities of daily living did not receive the ordered passive range of motion (PROM) therapy to both lower extremities. The resident's care plan included goals to prevent a decrease in range of motion and worsening of contractures, and physician orders were in place for PROM to both upper and lower extremities. However, the PROM therapy for the resident's lower extremities was discontinued on 2/5/25 without an updated referral from the therapy department, and the resident subsequently only received PROM to the upper extremities. Interviews with facility staff, including the Restorative Nurse Assistant, Director of Nursing, and Physical Therapy Assistant, confirmed that the lower extremity PROM was stopped without proper authorization or a new therapy referral, despite the resident's ongoing risk for contractures due to immobility. Documentation review showed that the last lower extremity PROM was provided on 2/13/25, and facility policy required restorative nursing care as needed to promote optimal safety and independence. This lapse in care resulted in the resident not receiving the necessary services to maintain or improve range of motion as outlined in their care plan and physician orders.