Failure to Provide Range of Motion Services Resulting in Contracture
Penalty
Summary
The facility failed to provide adequate services to prevent an avoidable decline and the development of a contracture in a resident with a history of cerebral infarction and limited range of motion (ROM). The resident was observed with her left leg bent at a 90-degree angle, unable to straighten it, and reported not receiving ROM exercises or splinting. Review of therapy records showed that no contracture was present at the time of admission, but a significant contracture developed over time, as documented in a later therapy evaluation. Progress notes indicated swelling and contraction of the left lower extremity, but there was no evidence of timely intervention or consistent ROM exercises being provided. Interviews with staff, including an LPN and the Rehabilitation Director, confirmed that the resident had not received therapy or documented ROM services, and that there was no restorative program in place. The Rehabilitation Director assumed that CNAs were providing ROM during care, but could not provide documentation to support this. The Administrator also confirmed the absence of documentation showing that ROM exercises were performed by either CNAs or therapy staff. Facility policy required assessment, recognition, and management of functional impairment, but these procedures were not followed, resulting in the resident's avoidable decline in mobility.