Failure to Document and Maintain Restorative Programs After Staff Departure
Penalty
Summary
The facility failed to provide documentation and rationale for discontinuing restorative programs for three residents after the designated Restorative Aide left the restorative nursing department. Record reviews showed that for each resident, restorative programs such as active range of motion exercises and other therapeutic activities were discontinued on the same date, with no evidence of monthly restorative program reviews or documented reasons for stopping the interventions. The residents involved had varying degrees of cognitive impairment and physical limitations, including needs for assistance with ambulation, dressing, and other activities of daily living, as well as diagnoses such as diabetes, obesity, muscle weakness, heart failure, anxiety, and depression. Interviews with facility staff revealed that the MDS Coordinator, who was responsible for overseeing the Restorative Program, had minimal training and had not completed any charting or reviews of restorative plans since assuming the role. The discontinuation of all restorative programs was attributed to the absence of a trained Restorative Aide, and no alternative arrangements or documentation were made to continue or review the programs. The Director of Nursing confirmed that all restorative programs were resolved or discontinued for staff convenience, and there had been no RN monthly restorative reviews for any residents in the past six months.