Failure to Maintain Resident Ambulation Due to Inadequate Documentation and Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident maintained the ability to perform activities of daily living, specifically ambulation, without a documented medical reason for decline. Staff did not consistently document attempts to walk the resident or record refusals, and there was a lack of consistent supervision during ambulation as recommended by physical therapy. The care plan did not address the resident's fear of falling, despite this being identified as a barrier to participation in walking activities. The resident had a history of falls and was previously able to ambulate independently for short distances, as documented in the Minimum Data Set (MDS). Over time, the resident's ability to walk declined, and she began using a wheelchair. Interviews with staff revealed that the resident stopped walking due to fear of falling, and staff confirmed that there was no walker in her room. Documentation showed sporadic and inconsistent ambulation attempts, with staff sometimes providing assistance but not always following the recommended supervision or documenting refusals. The physical therapist noted that the resident was too fearful to participate in walking during evaluation and recommended psychiatric assessment before starting a rehabilitation program. However, the psychiatric evaluation did not address the resident's fear of falling, and the care plan was not updated to include interventions for this issue. Facility policies required documentation of ambulation and assistance as needed, but these were not consistently followed, contributing to the resident's decline in mobility.