Failure to Implement Restorative ROM Interventions for Resident With Contracted Hand
Penalty
Summary
The deficiency involves the facility’s failure to implement restorative therapies and interventions to maintain or improve range of motion (ROM) and prevent contracture for a resident with known functional limitations. The facility’s Restorative Nursing Program policy requires that each resident be screened for restorative nursing upon admission, annually, quarterly, and with any significant change in function, and that appropriate residents have individualized restorative programs with goals, measurable objectives, and documented interventions and responses. The resident in question was admitted with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, COPD, seizures, and heart failure. A Minimum Data Set (MDS) assessment documented intact cognition, functional limitation in ROM to upper and lower extremities on one side, dependence in dressing, hygiene, and transfers, and that the resident was not in a Restorative Nursing Program. Despite these identified ROM limitations, the resident’s current care plan contained no documentation regarding her contracted left hand and no interventions to prevent further decrease in ROM. A Restorative Observation assessment documented that the resident was not receiving restorative programs for PROM (passive ROM) or AROM (active ROM). During observation, the resident was seen lying in bed with a contracted left hand, and in interview she stated she had minimal movement in her left hand and that nothing was being done for it. The Administrator confirmed there was no documentation of any restorative rehabilitation attempts for this resident and acknowledged that, although the resident frequently refused care, there was no documentation related to restorative care and that no restorative tasks had been implemented for her until very recently.
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