F0688

D

Failure to Assess and Provide ROM Services for Resident With Post-Stroke Right-Sided Weakness

Lakeside, Arizona Survey Completed on 11-19-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate treatment and services to maintain or improve range of motion (ROM) for a resident with a history of cerebrovascular accident and right-sided weakness. The resident was admitted with dementia, hemiplegia/hemiparesis following cerebral infarction, cerebral atherosclerosis, dysphagia, and dysarthria. Initial OT and PT evaluations in 2021 documented functional deficits in ADLs, strength, functional mobility, cognition, bed mobility, transfers, gait, balance, strength, and endurance, but upper extremity ROM was within normal limits at that time. Subsequent clinical documentation over 2024 and 2025, including NP notes, IDT care conference notes, quarterly nursing summaries, therapy screening, and provider progress notes, did not identify or document any limitations in upper extremity ROM, any ROM treatment or services, or any decline in ROM. The annual MDS did not code for therapy, restorative nursing, or splint/brace use, and there was no care plan developed with interventions specifically addressing limited ROM.

Surveyor observations in September 2025 showed that the resident consistently demonstrated significant right upper extremity posturing and apparent contracture-like positioning. During multiple observations, the resident was seen sitting in a wheelchair, eating independently with the left hand, while the right wrist was bent downward toward the underside of the forearm, and the right thumb and pointer finger were bent inward toward the palm. The right wrist and hand remained in this position during different activities, including self-propelling the wheelchair using the left hand and side rails, and there was no splint or brace in place on the right wrist or hand during any of these observations. Despite these visible limitations, the clinical record contained no assessment of the extent and limitations of joint movement since the 2021 therapy evaluations and no documentation that ROM services were provided, maintained, or declined.

Interviews with staff further demonstrated the lack of appropriate ROM assessment and services. A CMA reported that the resident had a severe stroke, had right-sided weakness, could not move the right arm, open or close the right hand, or move the fingers, and that the right wrist and fingers were now stiff and hard. The CMA stated the resident was not currently on therapy or an RNA program, that therapy and splint devices had been offered in the past but reportedly refused by the resident, and that she occasionally attempted exercises during care but the resident would pull his arm away. She also stated she was not aware of any recent therapy screen for further ROM decline. The DON described expectations that staff assess residents when issues are identified, implement interventions, notify providers, and collaborate on care, and the director of rehabilitation stated that residents must be screened by therapists. However, the record lacked evidence of ongoing ROM assessment, documented refusals, or a care plan with interventions to address the resident’s limited ROM, resulting in the cited deficiency.