Failure to Provide Consistent ROM Treatment and Orthotic Management for Contracted Right Leg
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services to maintain or improve range of motion (ROM) for a resident admitted with limited ROM and a right leg contracture. The resident had diagnoses including severe protein malnutrition, stroke, pressure ulcer, contracture of the right lower leg, and seizures, and MDS assessments documented limited ROM in both lower extremities and dependence on staff for ADLs. On observation, the resident’s right leg was found to be severely contracted and completely bent, with inability to fully extend. The care plan identified an alteration in musculoskeletal status related to the right leg contracture, and physician orders and PT documentation showed that the resident was to receive PT services, including evaluation for and use of an orthotic device to inhibit abnormal positions. PT documentation showed that the initial PT evaluation did not include objective measurements of lower extremity strength, degree of contracture, or specific functional limitations of the lower extremities. PT notes over time documented active assist ROM and gentle manual stretching to the bilateral lower extremities and specifically to the right lower extremity, but consistently indicated the resident could not return ROM demonstrations independently. A goal was established for the resident to safely wear the least restrictive splinting/orthotic device one hour on and one hour off without skin irritation. The orthotic device for the right knee was introduced and applied on several documented dates, but the resident was only able to tolerate about 15 minutes of wear due to pain, and there was no further documentation of the device being used after a short trial period. Subsequent PT recertifications continued to reference therapeutic exercises, gentle manual stretching, and that treatment to prevent further decline "may include" orthotic management and training, but there was no documentation explaining why the orthotic device was not continued or re-trialed after its initial brief use. Interviews with PT staff and the Director of Rehabilitation revealed that the therapist who performed the initial evaluation worked PRN and was unavailable, that staff were unaware when the orthotic was ordered or why it was discontinued, and that there was no documentation of initial lower extremity strength or functional ROM. The restorative nurse reported that the right knee contracture appeared the same at the time of interview as at PT discharge, and that the resident sometimes refused interventions due to pain. Overall, the record lacked adequate assessment data and documentation of consistent orthotic use or clinical rationale for discontinuing the orthotic device, despite the resident’s known right leg contracture and limited ROM.
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