Failure to Provide Ordered Restorative Exercise Programs
Summary
The facility failed to provide ordered restorative exercise programs for 6 of 6 residents reviewed for restorative exercise services. The report identified that residents with functional maintenance programs (FMPs) were not consistently receiving the exercises and mobility activities that had been ordered after discharge from therapy, and the restorative logs showed very limited completion of the programs over the review period. The facility’s own policy stated that residents with limited ROM or mobility would receive appropriate treatment and services to increase or maintain ROM and mobility, and that a trained nursing assistant would complete restorative care and document the time provided. For one resident, the record showed severe cognitive impairment, inability to ambulate, osteoporosis, Alzheimer’s disease, weakness, and a history of fractures. Therapy orders and restorative instructions directed upper and lower extremity exercises, standing, and transfer-related activities, but the restorative logs documented only one completed exercise session and three refusals over the review period. When the resident was observed with therapy staff, she became visibly weak and shaky toward the end of the exercises. For another resident with intact cognition, paraplegia, chronic pain, and impaired ROM to both lower extremities, the restorative plan called for upper and lower extremity ROM and stretching, but the logs showed only five exercise sessions and one refusal during the review period. A third resident with severe cognitive impairment and non-ambulatory status had a restorative plan to maintain lower extremity ROM and strength, including NuStep, seated exercises, and standing with a walker, yet the log showed only three completed sessions and three refusals out of 105 opportunities. Another resident with dementia, repeated falls, dizziness, and osteoarthritis had orders for daily PT and OT FMP exercises, but the restorative logs showed no completed restorative exercises and three refusals during the review period. A resident with dementia and diabetes had a restorative plan for passive ROM, stretching, and assistance with movement, but received restorative exercises only twice during the review period. One additional resident with a walking program as part of FMP received only two exercise sessions and no ambulation services during the period reviewed. Staff interviews indicated that restorative aides were frequently pulled to the floor for resident care, that nursing assistants were expected to provide ambulation, and that documentation did not always reflect refusals or whether residents had been offered the exercises.
Penalty
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Restorative splinting program not implemented for a resident with bilateral hand contractures. The resident had Brown-Sequard syndrome, quadriplegia, and limited ROM, and the care plan called for carrot finger orthoses and related hand positioning measures. Observations showed the splint was not in place, staff were unsure the interventions were being done, the resident said he was not receiving the program, and the orthosis was found soiled and stored by the bed. The DON confirmed there were no active physician orders for the contracture interventions and the restorative task had been resolved.
A resident with a history of stroke, contractures, and vascular dementia had physician orders and a care plan requiring a left-hand palm protector or hand roll splint to be applied daily and nightly with skin checks and hand hygiene. The Treatment Administration Record indicated these interventions were consistently completed, but repeated observations over several days showed the resident without any palm protector or splint in the affected hand while in bed, in a wheelchair, and during activities. An RN confirmed the device was not in place and had been missing from the room for several days, resulting in a failure to provide ordered ROM support for the resident’s contracture.
A resident with quadriplegia and hand contractures did not receive prescribed rolled washcloths or splints to both hands as ordered, and staff confirmed the absence of a restorative program to maintain or improve range of motion after therapy services ended. Observations and staff interviews verified that the resident's contracture interventions were not in place, and no system existed to prevent further decline in functional abilities.
Several residents with complex medical conditions did not consistently receive restorative nursing services as outlined in their care plans, including ambulation, ROM exercises, and ADL support. Documentation frequently showed missed or unperformed interventions, and staff interviews confirmed a lack of knowledge and inconsistent implementation, affecting the residents' functional maintenance.
A resident with bilateral hand contractures and multiple psychiatric diagnoses did not receive a recommended splint and brace program after discharge from OT. Despite OT recommendations for bilateral hand splints and ROM exercises, there were no physician orders or restorative program in place, and staff confirmed that no such interventions were implemented.
Two residents with contractures did not receive their physician-ordered splint devices as required. Despite clear orders and care plan interventions for the use of a palm protector and a c-roll splint, observations over several days showed that neither device was applied. Staff interviews revealed confusion about responsibility for applying the devices, and facility policy regarding splint use was not followed.
Restorative Splinting Program Not Implemented for Resident With Bilateral Hand Contractures
Penalty
Summary
The facility failed to ensure a restorative splinting program was implemented for one resident with bilateral hand contractures and limited range of motion. Resident #49 had diagnoses including Brown-Sequard syndrome, quadriplegia, venous insufficiency, contracture of muscle, and reduced mobility. The care plan identified that the resident would benefit from a restorative splinting program and specified that right and left hand carrot finger orthoses were to be applied with evening care and removed with morning care, with skin integrity checks during application and removal. However, the resident’s restorative nursing task was marked resolved on 03/12/25, and at the time of survey there were no active physician orders for the bilateral hand splinting program. Observations on 01/21/26 and 01/27/26 showed the resident did not have the carrot splint, or its equivalent, in place. During interview, an LPN confirmed the resident had bilateral hand contractures and had not been seen wearing the orthosis or rolled cloths, and was unsure whether night shift was applying the care planned interventions. The resident stated he was not currently receiving splinting programs on his bilateral hands and identified the carrot orthosis, which was found soiled with dust on a food storage rack by the bed. The DON confirmed there were no active physician orders for the bilateral hand contractures and was unsure why the restorative task had been resolved. The record also showed the resident had functional limitation in ROM in both upper extremities and that nursing was managing the contracture impairment.
Failure to Implement Ordered Palm Protector for Contracture Management
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered range of motion support for a resident with a left-hand contracture. The resident was admitted with multiple diagnoses including stroke, contractures, vascular dementia, hypertension, depression, and anxiety, and required staff assistance with ADLs while having intact cognition. Physician orders directed that a left-hand palm protector be applied each morning and removed at bedtime with skin integrity checks each shift, and that the resident tolerate a hand roll splint or palm protector nightly, with the left hand thoroughly washed and dried before and after use. The resident’s ADL functional status care plan also specified use of a palm protector to the left hand for contracture management. The Treatment Administration Record for the review period showed these orders as completed as written. However, multiple observations over several days showed the resident without a palm protector or hand roll splint in the left hand while in bed, in a wheelchair, and participating in activities. On each observed occasion, no palm protector was visible despite the active orders and documented completion on the TAR. In an interview, an RN confirmed that the resident did not have a palm protector in place and reported that the device could not be found in the room and had been missing for several days. This discrepancy between physician orders, care plan, documented implementation, and actual practice led to the cited deficiency for failure to maintain range of motion for a resident with contracture.
Failure to Maintain Restorative Program and Hand Contracture Interventions
Penalty
Summary
The facility failed to implement a restorative program to prevent the decline of residents' functional abilities, specifically for a resident with contractures of both hands. The resident had multiple diagnoses, including quadriplegia and contractures, and physician orders directed that rolled washcloths be applied to both hands twice daily. The care plan also included this intervention. However, observations revealed that the resident's hands were clenched in a tight-fisted position without the prescribed splints or washcloths in place. This absence was verified by nursing staff during the survey. Interviews with facility staff, including LPNs and the Therapy Director, confirmed that there was no restorative program in place to address range of motion exercises or to implement therapy recommendations after therapy services were discontinued. The Therapy Director acknowledged that residents who had received therapy services were at risk for functional decline due to the lack of restorative follow-up. The Assistant Director of Nursing also verified the absence of a restorative program and the failure to maintain the resident's hand splints as ordered.
Failure to Provide and Document Restorative Nursing Services per Care Plans
Penalty
Summary
The facility failed to provide restorative nursing services as outlined in the care plans for four residents who were at risk for decline in range of motion (ROM), mobility, and activities of daily living (ADL) performance. Each resident had individualized care plans and therapy discharge recommendations specifying daily restorative interventions such as ambulation with assistive devices, active and passive ROM exercises, and support with ADLs. Despite these documented interventions, point of care documentation revealed frequent omissions, with services marked as not applicable (N/A) or left blank on multiple days and shifts for all four residents. Interviews with staff, including CNAs and facility leadership, confirmed that restorative services were inconsistently provided. One CNA reported not performing restorative services due to a lack of knowledge and stated that there was no designated restorative aide. The Corporate Mobile DON and Regional Director of Clinical Services acknowledged ongoing inconsistencies in the provision and documentation of restorative care, attributing some of the lapses to agency staff, who were nonetheless expected to follow the care plans. Residents also reported that restorative exercises were not being performed as intended. The affected residents had significant medical histories, including Parkinson's disease, major depressive disorder, chronic obstructive pulmonary disease, muscle wasting, Alzheimer's disease, and dementia. Their care plans were designed to maintain or improve their functional abilities and prevent further decline. However, the facility's failure to consistently implement and document restorative nursing interventions as required by the care plans resulted in a deficiency affecting multiple residents.
Failure to Implement Splint/Brace Program for Resident with Hand Contractures
Penalty
Summary
The facility failed to implement a splint and brace program for a resident with bilateral hand contractures, as identified through medical record review, observation, staff interviews, and facility policy review. The resident had a history of bipolar disorder, anxiety, depression, suicidal behavior, and contractures, and was dependent on staff for care, bathing, and transfers. Occupational therapy (OT) had previously recommended the use of bilateral hand splints, passive range of motion (PROM) exercises for the left hand, active range of motion (AROM) exercises for the right hand, and verbal cues for self-feeding. However, there were no physician orders in place for the use of splints or for a restorative program involving PROM and AROM exercises. Observation revealed that the resident was not using splints, and interviews with the Therapy Director and Assistant Director of Nursing confirmed that no restorative program had been implemented following OT discharge. The OT had not written orders or completed an evaluation for the implementation of a splint and ROM restorative program, and the nursing restorative staff did not have a program to follow. Facility policy indicated that properly used splints and braces can enhance mobility and protect extremities, but this was not carried out for the resident in question.
Failure to Provide Physician-Ordered Splint Devices for Residents with Contractures
Penalty
Summary
The facility failed to provide physician-ordered splint devices to residents with contractures, as evidenced by the care of two residents reviewed for range of motion. One resident, with diagnoses including paralytic syndrome, polyneuropathy, and contracture of the right hand and wrist, had a physician order and care plan intervention for a right palm protector to be applied daily for up to eight hours. Despite this, multiple observations over several days showed the resident was not wearing the palm protector. Interviews with nursing staff and CNAs revealed confusion and lack of clarity regarding responsibility for applying the device, with none of the interviewed staff having applied the palm protector as ordered. Another resident, diagnosed with contracture of the left hand and elbow as well as hemiplegia and hemiparalysis, had an active physician order and care plan for a left c-roll splint to be applied for six hours daily. Observations on multiple occasions found the resident in bed with contracted extremities and no splint or device in place. Staff interviews confirmed the resident had not had the splint applied during the observed period. Facility policy indicated that splints and braces are to be used to enhance mobility and maintain alignment, but these were not provided as ordered for the residents in question.
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