Failure to Involve Residents in Changes to Restorative Care Plans
Penalty
Summary
The facility failed to ensure residents were provided the opportunity to participate in decisions about their care and treatment, specifically related to restorative nursing and therapy services. Facility policy dated 03/2022 stated that residents had the right to participate in the development and implementation of their comprehensive person-centered care plan, including determining the type, amount, frequency, and duration of care, receiving the services in the care plan, and seeing and signing the care plan after significant changes. For one resident with diabetes, paraplegia, and depression, whose comprehensive assessment showed intact cognition and a need for partial to maximum assistance with ADLs, the medical record documented a restorative nursing AROM program at a frequency of six times per week. The care plan, initiated on 10/30/2025, was later modified on 03/05/2026 to reduce the AROM frequency to three times per week. During interview, this resident reported frustration about the change in therapy services, stating they were not informed of the reduction from six to three days per week and that session length had been cut from 30 minutes to 20 minutes. A second resident, with left-sided weakness/paralysis after a stroke, lung disease, and hypertension, was assessed as dependent on one to two staff for ADLs and having moderately impaired cognition. This resident’s care plan showed an AROM program initiated at six times per week, which was also reduced to three times per week on 03/05/2026. In an interview, the resident’s representative stated that at a recent care conference they were told the resident was receiving restorative nursing services every day, but they did not know if that was occurring and were not informed of any changes in services. These findings showed that changes in restorative/AROM frequency and duration were made without informing or involving the residents or their representative as required by the facility’s person-centered care planning policy.
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