Failure to Provide Necessary Care, Therapy, and Restorative Services
Penalty
Summary
The facility failed to provide necessary care and services to ensure residents maintained their highest physical well-being, as evidenced by multiple deficiencies in monitoring, documentation, and adherence to physician orders for five sampled residents. For one resident with a right upper arm fracture, there was no consistent monitoring for pain, redness, swelling, or warmth of the extremities, despite care plan interventions requiring such assessments. Documentation was lacking for musculoskeletal assessments and CNA care during specific shifts, and there was no evidence that pain observed by PT staff was reported to nursing. Interviews with staff confirmed that assessments were not completed and that signs of injury were not always checked or documented. The facility also failed to follow physician orders for physical therapy (PT) and occupational therapy (OT) treatments for two residents. Records showed missed PT and OT sessions over several weeks, with the rehabilitation department prioritizing other hospital patients over those in the skilled nursing facility. The Director of Nursing acknowledged the lack of therapy documentation and confirmed that required treatments were not consistently provided as ordered. Additionally, the facility did not provide daily Restorative Nursing Assistant (RNA) services as ordered for four residents. Medical records revealed multiple dates where RNA services, including range of motion exercises and application of orthotic devices, were not performed or documented. Staff interviews indicated that on days with staffing shortages, the RNA was reassigned to CNA duties, resulting in missed restorative care. The Director of Nursing verified that these services were not provided on the specified dates due to staffing issues.