Failure to Provide and Document Ordered Restorative Therapy Services
Penalty
Summary
A deficiency occurred when the facility failed to provide restorative therapy services as ordered for a resident with diagnoses including spinal stenosis, multiple sclerosis, and fibromyalgia. The resident, who was alert and oriented and required extensive assistance with bed mobility and transfers, was observed lying in bed and confirmed not receiving consistent restorative therapy during the week. Physician orders specified skilled restorative nursing three times a week for 12 weeks, focusing on active range of motion (ROM) exercises for both upper and lower extremities. However, a review of the clinical record over a 14-day period showed that restorative therapy was only documented as provided on three out of six possible occasions. Further investigation revealed discrepancies in documentation, as a CNA reported providing restorative therapy on additional dates that were not recorded in the medical record. The Assistant Director of Nursing acknowledged the lack of accurate documentation and stated that the restorative program was under review. Facility policy requires that implementation of restorative nursing programs be documented in the delivery record or electronic medical record, but this was not consistently done for the resident in question.