Failure to Provide and Document Ordered Restorative Services
Penalty
Summary
The facility failed to provide restorative services as ordered and care planned for four residents, resulting in a deficiency related to maintaining or improving range of motion (ROM) and mobility. Despite having policies in place that required individualized restorative nursing programs, documentation, and regular evaluation, staff did not ensure that restorative services were consistently provided or properly documented. Observations, interviews, and record reviews revealed that residents with diagnoses such as chronic heart failure, COPD, muscle wasting, generalized weakness, and dependence on mobility aids did not consistently receive the restorative interventions outlined in their care plans and physician orders. For each resident, care plans and physician orders specified restorative programs such as use of NuStep equipment, ambulation with assistive devices, and strengthening exercises. However, documentation of these services was frequently missing or incomplete. Handwritten notes, rather than entries in the electronic medical record, were used by the restorative aide, who had not been trained on electronic documentation. Several residents reported infrequent or discontinued restorative sessions, and staff interviews confirmed that the restorative aide was often reassigned to work as a CNA on the floor, limiting the time available for restorative care. Interviews with staff, including the restorative aide, DON, and other nursing personnel, confirmed a lack of a systematic process to ensure restorative services were delivered as ordered. The restorative aide reported being pulled to floor duties frequently and not being able to consistently provide or document restorative care. The Director of Rehab and other staff acknowledged that recommendations for restorative therapy were made but not always followed through due to time management issues and lack of clear scheduling. As a result, residents did not receive the frequency or consistency of restorative services required to maintain or improve their functional abilities.