Failure to Provide Consistent ROM Interventions Resulting in Contractures
Penalty
Summary
A facility failed to provide consistent range of motion (ROM) exercises to a resident's left lower extremity (LLE) from admission until hospital transfer, resulting in the development of contractures. Initial assessments and therapy evaluations indicated that the resident had normal ROM in both lower extremities, with no contractures present. However, subsequent therapy notes and evaluations documented a progressive decline in the resident's left knee extension, with increasing difficulty in straightening the knee and performing transfers. Despite these changes, there was no documented change-of-condition evaluation or timely revision of the resident's care plan to address the decline in mobility. Therapy documentation showed that while some improvement in left knee extension was recorded over a short period, there were also periods with no improvement or worsening of the condition. The care plan addressing physical therapy and restorative nursing ROM was not updated to reflect the resident's declining ROM in the LLE, and there was a lack of documentation indicating that lower extremity ROM exercises were consistently provided. Interviews with facility staff confirmed that changes in the resident's mobility were not properly assessed or documented, and that contractures were not initially recognized or addressed in a timely manner. Upon hospital admission, the resident was found to have contractures in the LLE, along with multiple serious wounds, poor blood flow, and signs of infection and tissue death in the affected leg. The hospital team noted that the resident's poor nutrition, tight leg muscles, and compromised circulation would make wound healing difficult. The failure to provide consistent ROM interventions and to update care plans in response to the resident's declining mobility directly contributed to the development of contractures and associated complications.