Failure to Provide RN-Guided Restorative Nursing to Maintain ROM and Mobility
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement restorative nursing programs to maintain or improve residents’ range of motion (ROM), strength, and mobility under the direct guidance of an RN, as required by facility policy and based on comprehensive assessments. For one resident with a history of stroke and multiple psychiatric diagnoses, the admission MDS documented functional limitations in both upper and lower extremities and receipt of PROM, AROM, splint/brace assistance, bed mobility, transfers, and dressing/grooming. The resident’s care plan included a restorative focus with specific interventions such as resistive exercises, bed mobility, PROM, splint/brace use, and transfers, initiated by the DON/RN and later revised by a Restorative Nursing Assistant (RNA). The resident reported wanting to walk more and expecting a new leg brace and work on uneven bars, but staff were unaware of a new brace, and the RNA described creating the restorative program at readmission and defaulting to PROM when no AROM was present, using her own judgment on how far to stretch until resistance was felt. For a second resident with normal cognition and diagnoses including severe blood infection, diabetes, and a rare flesh-eating bacterial infection, the MDS showed independence with dressing, toileting, bed mobility, and transfers, and supervision for ambulation without ROM limitations. The MDS also documented receipt of AROM, bed mobility, transfers, and dressing/grooming over the look-back period. The care plan contained a restorative focus with interventions for ambulation, AROM, bed mobility, dressing/grooming, and transfers, as well as a self-care performance deficit focus emphasizing independence with basic ADLs. However, the resident stated he had only attended restorative nursing once since admission, despite having exercise equipment in his room and additional resistance bands provided by staff. The RNA reported that this resident used overhead pulleys, bicep curls with and without light weights, and AROM for lower extremities, and that the restorative program had been written on the care plan by another staff member. Interviews with staff and review of facility practices showed that restorative programs were being developed and modified primarily by RNAs and an MDS Coordinator who was an LPN, rather than under the direct guidance of an RN as required by the facility’s restorative policy. The DON explained that RNAs write programs, take them to the MDS Coordinator, and then to the DON, and that RNAs can write programs and place them directly into care plans, with feedback largely coming from RNAs and residents. The DON acknowledged there was no documentation showing her active involvement in program development, that she only reviewed care plans quarterly, that RNAs should not be assessing residents for program development and changes, and that she was unaware of the training RNAs had for restorative work. Additional interviews revealed that staff responsible for restorative programming were trained informally by other non-RN staff, with one staff member self-taught through books and internet searches and without formal restorative training, contrary to the facility’s policy that programs be set up by restorative supervision and the MDS/Care Plan Coordinator and based on comprehensive assessment.
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