Failure to Provide Ordered Restorative Ambulation Services
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative rehabilitation services as ordered for a resident with mobility needs. The resident was admitted on 08/22/25 and had a physician’s order dated 09/16/25 stating she may participate in a Restorative Nursing Program, but the order did not specify the frequency of services. A physical therapy discharge note dated 09/24/25 recommended discharge to long-term care with a restorative nursing program for ambulation two times per day for at least five days a week with a front wheel walker and staff setup and supervision. However, the resident’s quarterly MDS assessment showed zero days of participation in a restorative nursing program in the seven days reviewed. During an interview, the resident reported she was supposed to be walking daily with restorative nursing and stated she was walked the previous day for the first time in four months because state surveyors were in the building. Staff interviews confirmed that the restorative program was not implemented as ordered. The RNA reported that 11/17/25 was the first day the restorative program was “back in session” and that she ambulated the resident that day, stating it was the first time in a while because there had been no restorative program. She also stated the resident should be ambulated daily but was not ambulated on 11/18/25 and 11/19/25 because the RNA was pulled to work as a CNA on the floor for her entire shift. The Restorative Nurse confirmed that the resident was ordered to start the restorative program on 09/16/25 but did not begin until 11/17/25 due to staffing issues, and that the expectation was for the program to be followed as ordered and completed by the RNA. The Regional Nursing Consultant confirmed there was no active restorative program in September 2025, that the resident should have been care planned with a correctly written order specifying frequency, and that while CNAs on the unit were assisting with ambulation and documenting refusals, the resident and others in the program did not have appropriate restorative care planning in place.
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