F0688

D

Failure to Implement Restorative Ambulation Program for Resident With Limited Mobility

York, Pennsylvania Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The facility failed to provide appropriate restorative nursing services to maintain or improve range of motion and mobility for a resident with limited mobility. Facility policy on Restorative Nursing required that restorative programs be patient-specific and implemented according to the care plan to promote the patient’s ability to live as independently and safely as possible. The resident’s diagnoses included deforming dorsopathy and abnormalities of gait and mobility. A physical therapy discharge summary documented that the resident was to be referred to a restorative ambulation program to provide supervision and support for longer-distance ambulation with a rolling walker on the unit to attend activities. The resident’s care plan included a restorative ambulation focus with a goal for the resident to walk throughout the unit at least two times per day.

Despite these orders and care plan interventions, restorative nursing documentation for the resident showed the program was repeatedly marked as “not applicable” on numerous dates, indicating that the restorative ambulation program was not being carried out. The resident reported that since discharge from therapy, she had only been assisted to walk in the hallway with her walker two to three times and expressed that it would be nice to walk every day. The DON later stated that the restorative program was titled incorrectly in the electronic system, which could have caused confusion for nurse aides, and that the task had been updated to reflect walking 100–150 feet. However, even after this correction, the restorative program continued to be documented as “not applicable,” and the DON acknowledged he would need to follow up on why the program was still not being implemented as expected.