Failure to Follow Orders for Palm Guard and Bunny Boots
Summary
The facility failed to follow physician's orders for a resident with cerebral palsy, cognitive communication deficit, dysphagia, aphasia, hemiplegia, and muscle weakness who had significant cognitive impairment, upper and lower extremity impairment, and needed moderate to total assistance with dressing, grooming, bathing, and mobility. The resident's Braden Scale score was 11, indicating high risk for developing wounds. The care plan identified the resident as at risk for skin breakdown related to impaired mobility, incontinence, and impaired activities of daily living ability, and included interventions for bunny boots to both feet at all times as tolerated and a right hand palm guard. The resident had a physician's order for a palm guard on the right hand daily and off at night every shift, but observations showed the resident was often not wearing the palm guard and it was frequently found on a tray table, dresser, or not in use. There was no documentation showing the resident refused the palm guard, and there was no documentation showing when the palm guard was applied. A restorative nursing task also directed staff to place the splint on the resident's right hand if not already wearing it, but the restorative aide stated the resident often refused and that refusals were documented on paper first rather than in the medical record. The resident also had a prior physician's order for bunny boots to both feet at all times every day and night shift for prevention, but that order was discontinued on 11/17/25 and there was no current physician's order on the POS for soft boots despite staff stating the resident should wear them. Observations showed the resident was sometimes not wearing the bunny boots while in bed, with the boots left on a tray table or out of reach, although at other times the resident was observed wearing them. Interviews with the Wound Care Nurse, Rehabilitation Director, Restorative Aide, Unit Manager, and DON confirmed that the boots and palm guard were expected to be used, that documentation of refusals should have been present, and that the bunny boot order may have been discontinued by mistake.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Complete Ordered Passive ROM Exercises: A resident with moderate cognitive impairment, CVA-related left hemiplegia/hemiparesis, and total dependence for mobility had a physician order for passive ROM to the left arm two to three times daily. During observation, an NA provided routine ADL care but did not perform the ordered ROM despite posted instructions in the room. Staff interviews and EMR review showed the restorative task was not documented as completed, and the DON and OT/PT director could not verify that the ordered ROM had been carried out.
Restorative nursing programs were canceled for multiple residents with contractures and major ROM limitations without documented clinical rationale. A resident with severe contractures had repeated gaps in PROM and splint documentation, while other residents with cerebral palsy, hemiplegia, quadriplegia, or brain injury had PROM, AROM, walking, and aquatic programs discontinued. Staff reported the LTC lacked a consistent restorative program, had no restorative aide, and did not have enough trained staff to provide the interventions.
Failure to Implement Restorative Nursing Program: A resident with CVA, hemiplegia, hemiparesis, and severe cognitive impairment did not consistently receive the planned restorative nursing services needed to maintain mobility. PT discharged the resident to the RNP and directed daily ROM exercises, and a physician also ordered active-assisted to passive ROM, but review of the task report, documentation report, and MAR showed no documented evidence that the restorative ambulation program had been implemented. The DON confirmed the facility did not consistently carry out the planned restorative nursing program as recommended by PT.
Failure to provide and document splinting and ROM services: A resident with muscle weakness and bilateral hand contractures had hand splints observed stored in a basin near the bedside, while the chart lacked a splint wearing schedule and did not show documentation that the splints were applied. OT discharge instructions established a restorative splint and brace program, with staff educated to don and doff the splints, complete skin checks, and provide passive ROM before splint use, but TARs and nurse aide documentation did not reflect the resident wearing the splints.
Failure to use therapy-ordered positioning equipment for a resident who needed help maintaining alignment in bed. The resident had morbid obesity, DM, bladder CA, and CKD, and PT documented dependence for repositioning, a tendency to lean left, and staff education on using a wedge cushion and bolster for supine positioning. During survey, the resident said staff did not place the equipment in the bed unless asked, and observations showed the wedge and bolster stored elsewhere while the resident was in bed; a CNA confirmed the equipment was not being used as intended.
Failure to Measure and Maintain ROM for Two Residents: Two residents with significant mobility and ROM limitations did not receive fully documented OT ROM measurements, and one resident also missed PROM and splinting after PT/OT discharge. One resident with hemiplegia, contractures, and severe cognitive impairment had OT evals that noted impaired ROM in both arms but did not objectively measure the joints, and RNA services for PROM and splint use were not provided as ordered for a period after therapy ended. Another resident with muscle weakness, CABG history, atrial fibrillation, and a healed fracture had an OT eval that noted right shoulder ROM impairment but did not include goniometer measurements.
Failure to Complete Ordered Passive ROM Exercises
Penalty
Summary
The facility failed to ensure physician-ordered passive range of motion (ROM) exercises were completed for a resident with moderate cognitive impairment, cerebral infarction with left-sided hemiplegia and hemiparesis, and dependence on staff for mobility. The resident’s physical therapy order directed staff to complete passive ROM to the left arm two to three times daily and to follow restorative nursing instructions posted in the room. The care plan also directed nursing staff to provide passive ROM exercises to the left arm two to three times daily and to refer to the restorative rehabilitation handout posted on the wall and closet. During observation, a nursing assistant provided the resident’s personal care, including bathing, grooming, and oral care, but did not perform the ordered passive ROM exercises even though the instructions and photographs were posted in plain view. Staff interviews showed they relied on the EMR task tab to confirm whether restorative care had been completed, but the task was not documented as completed. The DON and OT/PT director were unable to verify in the EMR that the resident’s passive ROM exercises had been completed, and the facility’s documentation for restorative nursing showed missing or absent entries for the resident’s passive ROM care.
Restorative Nursing Programs Canceled Without Clinical Rationale
Penalty
Summary
The facility failed to ensure residents with contractures received necessary restorative nursing care to maintain or improve functional potential. Management canceled passive range of motion (PROM), active range of motion (AROM), walking, aquatic, and other restorative programs for multiple residents without documenting a clinical rationale in the progress notes. The facility also lacked trained or dedicated staff to deliver restorative care interventions, and staff statements reflected that restorative care was not being consistently provided. Resident #2 had severe cognitive impairment, functional ROM limitations in all extremities, and diagnoses including right elbow contracture, hemiplegia/hemiparesis, and dystonia. The record showed prior OT and PT, but no restorative care during the look-back period. The care plan addressed contracture-related skin integrity risk and included positioning devices, splints, and rolled washcloths. Documentation showed multiple missed entries for restorative PROM and splint/brace tasks across March, May, and June 2026. The record also showed the facility discontinued bilateral resting hand splints and later used rolled washcloths and a cervical cushion/towel roll, with additional gaps in documentation. Staff and family reported that Resident #2 had worsening stiffness, contractures, and reduced function, and therapy staff stated the facility lacked staff to perform PROM or AROM programs and had not had a restorative program since July 2025. Residents #5, #6, #7, #8, and #10 also had significant functional limitations and diagnoses associated with contractures, cerebral palsy, hemiplegia, quadriplegia, or brain injury. Resident #5 had no restorative program in place since admission. Resident #6 had a PROM program to both upper extremities that management canceled, with no progress note documenting why. Resident #7 had a walking program and AROM grip-strength program canceled without explanation. Resident #8 had a PROM program for upper and lower extremities canceled without explanation. Resident #10 had an assisted AROM aquatic program and a PROM program canceled without documented rationale. Staff statements confirmed CNAs did not have time to do restorative care, no restorative aide was staffed, the pool program was stopped because there was no lifeguard, and the facility had not maintained a consistent restorative program for months.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident. Resident 115 was admitted with diagnoses including cerebral infarction, hemiplegia, and hemiparesis, and the Quarterly MDS dated April 9, 2026, showed the resident was severely cognitively impaired with a BIMS score of 02. The facility’s Restorative Nursing Programs Policy stated that maintenance and restorative services would be provided to maintain or improve residents’ abilities to the highest practical level, and that residents would receive maintenance nursing services as needed by CNAs. The clinical record showed that PT services were provided from March 22, 2025, through April 18, 2025, and the PT discharge summary recommended referral to the facility’s RNP to maintain the resident’s functional abilities. The discharge summary directed staff to provide ROM exercises through all planes of movement, 10 repetitions for two sets, for approximately 15 minutes daily, and a physician order dated September 29, 2025, directed active-assisted to passive ROM exercises through all planes of movement, 10 repetitions for two sets, for approximately 15 minutes daily. Review of the electronic task report, Documentation Survey Report v2, and MAR revealed no documented evidence that the restorative ambulation program had been implemented. The DON confirmed on June 30, 2026, that the facility failed to consistently implement the planned restorative nursing program for Resident 115 as recommended by PT to maintain the resident’s functional abilities and deter declines to the extent possible and to ensure the resident’s goals for ambulation were met.
Failure to Provide and Document Splinting and ROM Services
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate services, equipment, and assistance to increase range of motion and/or prevent further decrease in range of motion. Resident 7 had diagnoses including muscle weakness and contractures of the right and left hand. Observations on June 23, 2026, June 24, 2026, and June 25, 2026, showed bilateral hand splints in a basin near the resident’s bedside rather than in use. The resident had a physician order for bilateral hand/wrist splint skin checks every shift dated September 7, 2025, but the record did not include an order for a splint wearing schedule. The care plan included a focus for assistance/potential to restore to maximum level of function for mobility, but it did not include interventions for a splinting program. The resident received OT from March 23, 2026, through April 29, 2026, and the OT discharge summary stated the resident could tolerate bilateral resting hand splints for six hours daily, staff were educated on donning and doffing splints and skin checks, and a Restorative Splint and Brace Program was established for daily use. The facility’s restorative education form showed staff were educated that the resident was to wear the splints daily up to eight hours a day and that passive ROM to the fingers, wrists, and elbows was to be provided before donning the splints because the resident was totally dependent on staff for splint donning/doffing and hygiene. However, the treatment administration records and nurse aide task documentation did not show that the resident wore the splints, although nurses documented the ordered skin checks every shift. The DON confirmed there was no order indicating the splint wearing schedule and no documentation showing the splints were applied.
Failure to Use Ordered Positioning Equipment
Penalty
Summary
The facility failed to ensure therapy-ordered positioning equipment was used for a resident who needed assistance maintaining body alignment in bed. Resident #39 was admitted with diagnoses including morbid obesity, diabetes mellitus, bladder cancer, and chronic kidney disease. The resident’s quarterly MDS showed mild cognitive decline and substantial assistance was required for all ADLs except eating. The resident’s care plan was silent regarding positioning, and there was no physician order specifically addressing positioning equipment. Physical therapy documentation stated the resident was dependent for repositioning to maintain straight alignment in bed and that staff were educated on bolster placement to keep the resident centered and prevent a left lateral lean. A later PT note documented that the resident was provided a different wedge cushion due to discomfort with the prior one and that staff training was provided on supine positioning and use of the wedge cushion. However, during the survey the resident stated staff failed to place the wedge or bolster in the bed unless she asked for it, and observations showed the wedge cushion in the wheelchair and the bolster in the recliner while the resident was in bed. A CNA confirmed the equipment was not in the bed and stated it should be used when the resident was in bed.
Failure to Measure and Maintain ROM for Two Residents
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve ROM and mobility for two residents with limited ROM. One resident had a history of traumatic subarachnoid hemorrhage, left-sided hemiplegia, aphasia, dysphagia, contractures, and severely impaired cognition. The resident’s MDS indicated ROM limitation in both arms and legs and dependence for multiple ADLs. OT evaluations dated 5/6/2025 and 11/11/2025 documented impaired ROM in both shoulders, elbows/forearms, wrists, and hands, but neither evaluation included objective measurements of the impairments. The DOR stated that therapy staff are trained to measure joints with a goniometer and that the absence of measurements prevented monitoring for changes in ROM. For the same resident, PT and OT services ended on 8/19/2025, and physician orders dated 9/3/2025 directed RNA staff to provide PROM to both arms and legs five times per week as tolerated and to apply resting hand splints, elbow extension splints, knee extension splints, and ankle splints five times per week for four to six hours as tolerated. The OT discharge summary recommended 24-hour care, and the PT discharge summary recommended a restorative nursing program. However, the DOR stated the OT discharge summary did not include RNA services, and the resident did not receive ROM exercises and splint application from 8/10/2025 to 9/3/2025. During observation, the resident was lying in bed, unable to speak, with elbow and hand splints in place; PROM was later provided to both shoulders, elbows, wrists, and hands, and the resident’s elbows could not be fully straightened, with fixed bent positions noted in some fingers and knuckles. A second resident had diagnoses including muscle weakness, atherosclerosis of CABG grafts, atrial fibrillation, and a healed traumatic fracture. The resident’s MDS indicated unclear speech, severely impaired cognition, and dependence for toileting, showering, dressing, rolling, transfers, and sit-to-stand transfers. The OT evaluation dated 4/16/2026 documented a history of CABG, right humeral fracture, and right shoulder anterior dislocation with closed reduction, and noted right shoulder ROM impairment, but did not include objective ROM measurements. The DOR and the evaluating OT both stated that goniometer measurements are part of OT training and are used to establish baseline ROM and monitor improvement or decline, and the OT stated the resident’s right shoulder ROM should have been measured because it could affect ADLs.
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