F0688

D

Failure to Implement Recommended Restorative Nursing Program After PT Discharge

Lacey, Washington Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The facility failed to provide restorative nursing services as recommended for a resident with a right below-the-knee amputation. Facility policy stated that residents identified through the comprehensive assessment process as needing restorative nursing services would receive them, including interventions such as passive or active ROM, splint or brace assistance, bed mobility, transfer and walking training, dressing and grooming training, eating and swallowing training, amputation/prosthesis care, and communication training. The policy also required the discharging therapist, Restorative Nurse, or designated licensed nurse to communicate the restorative nursing plan to the appropriate restorative aide and provide necessary training.

The resident was admitted with a diagnosis including a right below-the-knee amputation and, per a quarterly MDS, had mild cognitive impairment, no behaviors, required staff assistance for ADLs, transfers, and mobility, and used a wheelchair. A PT Discharge Summary covering services from 08/18/2025 through 09/30/2025 documented recommendations for a Restorative Nursing Program and follow-up with a prosthetic company for further fittings. Review of the medical record showed no physician’s order for restorative nursing program services for this resident, and during interview the PT confirmed there was a recommendation for restorative services but no documentation that the resident received them.