A resident with intact cognition, ADL self-care deficits, and dependence on staff for ambulation and transfers did not receive the ordered restorative ROM program recommended by therapy. Although therapy issued recommendations for active ROM exercises to the lower extremities and nursing notes indicated that restorative referrals were received and that the resident was "continuing" a restorative program, there was no documentation that the specific exercises were carried out. Staff interviews revealed that therapy referrals to restorative were not effectively communicated, the restorative aide reported never receiving a PT referral and confirmed the resident did not receive restorative services, and nursing leadership acknowledged a lapse in administering the restorative program over an extended period, contrary to the facility’s restorative nursing policy.
Failure to Provide Scheduled Restorative ROM Program: A resident with quadriplegia, depression, bipolar disorder, and CVA had a care plan for restorative ROM and stretching 5-7 times per week, but restorative therapy was missed on multiple occasions. The resident stated therapy was not provided when the restorative aide was off duty, while the restorative aide said floor staff were supposed to complete it. CNAs said they were not aware they were expected to provide the restorative program, and the DON stated staff should complete the same routine when the restorative aide was absent. The facility had no policy for restorative therapy.
Failure to implement a revised RNP and provide AAROM: A resident with stroke, hip fracture, MS, impaired mobility, and intact cognition was ordered multiple restorative exercises including AAROM, standing, dowel work, and arm bike. During observation, a restorative aide/CNA had the resident attempt several lower-extremity exercises but did not provide hands-on AAROM when the resident could not complete them, and the updated RNP was not visible in the EHR restorative section because it had been entered in the wrong area. Records lacked documentation of several revised restorative activities, and the policy lacked specific direction for communicating and implementing revised RNPs.
A resident with paraplegia, spinal cord dysfunction, and dependence for several ADLs did not receive consistent PROM to BLE as directed in the care plan. Records showed 0 days of PROM during the MDS lookback period and limited documentation of restorative services, while the resident and restorative aide reported the exercises were often missed because staff were pulled to other duties and the program did not resume promptly after a hospital stay.
Failure to provide ordered restorative nursing services for a resident with quadriplegia and limited ROM. The resident’s care plan addressed PROM for the upper extremities but did not include lower extremity PROM or communication, even though nursing orders required daily PROM and daily restorative communication. The Restorative TAR showed the programs were documented only 8 of 30 days, with many missed or blank entries, and the resident reported not receiving services for several days. Staff said the RNA was often pulled to the floor during staffing shortages, and the DON and Administrator acknowledged the lack of documentation.
A facility failed to consistently provide restorative ROM services for two residents with limited mobility and dependence in ADLs. One resident reported therapy had stopped after admission and wanted therapy again, while the other said staff were frequently pulled to the floor. EHR review showed restorative tasks were scheduled, but documentation reflected missed or incomplete sessions, and staff said restorative aides were often reassigned to CNA duties, preventing the tasks from being completed as written.
Two residents with significant mobility and cognitive impairments did not consistently receive restorative AROM and walking programs as documented, and nursing records lacked routine review of participation, progression, or decline. Interviews showed the DON, MDS Coordinator, and CNA were using EHR tasks for restorative services, but the facility had no formal restorative program or policy and did not complete routine progress notes or evaluations.
The facility failed to ensure restorative nursing programs to maintain or improve ROM, strength, and mobility were developed and implemented under RN guidance for two residents. One resident with stroke-related ROM limitations had a care plan listing PROM, AROM, splint/brace use, and transfers, but the RNA reported independently creating the program at readmission, defaulting to PROM based on her own judgment, and was unaware of the resident’s expectation for a new leg brace and additional gait work. Another resident with normal cognition and no ROM limitations had a restorative care plan for ambulation, AROM, and ADLs but reported attending restorative nursing only once, despite staff describing multiple prescribed exercises. Interviews showed restorative programs were primarily written and adjusted by RNAs and an LPN MDS coordinator, with informal, non-RN training and no documented active RN oversight, contrary to facility policy requiring restorative programs to be set up based on comprehensive assessment and under appropriate supervision.
Surveyors found that the facility failed to provide appropriate ROM services and implement ordered interventions for two residents with post-stroke hemiplegia and hand contractures. One resident had a tightly contracted hand with fingernails pressing into the palm, no splint or padding in place, no therapy for the contracture, and no specific orders or care plan interventions addressing the hand, leading the resident to place tissues in the palm independently. Another resident had contracted fingers with no padding, reported no restorative exercises and no splint, despite a physician’s order for a left hand splint. The ARNP and OT cited insurance coverage issues and had not completed evaluations or treatments, and the DON was unable to identify what actions had been taken to follow the splint order, contrary to facility policy requiring therapy referral and provision of appropriate ROM interventions and equipment.
Failure to implement and document restorative programs for two residents. One resident with severe cognitive impairment and multiple chronic conditions had OT-recommended PROM for both UEs, but the care plan, Kardex, and EHR lacked the restorative program and staff reported it was not done consistently. Another resident with Parkinson’s disease and intact cognition had a care plan for walking and ROM restoratives, but documentation showed the walking program was completed only a few times over two months, with no refusals recorded; the resident wanted to walk more and the DON acknowledged the missing documentation.
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