Health inspection·December 5, 2024

§483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. § 72315. Nursing Service--Patient Care. (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures, and deformities. Such care shall include: (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. On 10/29/24 at 7:30 A.M., an unannounced visit was conducted at the facility for a recertification survey. The facility failed to prevent a decline in Resident 27's full movement potential of his hands (such as fully closing his hands to grasp or make a fist), which made it difficult for Resident 27 to cut up food items and fully grasp utensils during meals. In addition, this failure had the potential for Resident 27 to independently complete all other activities of daily living such as grooming, dressing and personal hygiene. A review of Resident 27's undated Admission Record indicated that Resident 27 was admitted to the facility on 1/27/18 with diagnoses including osteoporosis (condition in which bones become weak and brittle). A review of Resident 27's care plans dated 8/3/20 indicated, "Physical mobility needs...resident will remain free of complications..." The care plans did not indicate limited range of motion of both hands. A review of Resident 27's MDS (a clinical assessment tool) assessments dated 1/26/24, 4/25/24 and 7/24/24 was conducted. MDS Section GG0115 for all three MDS assessments titled, "Functional Limitation in Range of Motion" indicated "...0 [no impairment] ...Upper extremity [shoulder, elbow, wrist, hand] ..." A review of the occupational therapy evaluation for Resident 27 titled, "OT Evaluation & Plan of Treatment", dated 11/1/24, was conducted. The evaluation indicated, "...Eating...Long-Term Goals...Pt will tolerate wearing resting hand splint three hours per day...to improve digit [fingers] extension for functional engagement in ADL [activity of daily living] tasks...Musculoskeletal System Assessment...Contracture...Functional Limitations Present due to Contracture= Yes; Functional Limitations as Result of Contracture(s): limited functional ability to perform ADLs; pt baseline receive [sic] assistance for ADL tasks from CNA staff..." A review of the facility's policy and procedure (P&P) titled, "Resident Mobility and Range of Motion," dated July 2017 was conducted. The P&P indicated, "...Residents will not experience an avoidable reduction in range of motion [ROM]...Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in ROM..." During an initial tour of the facility on 10/29/24 at 9:40 A.M., an observation and interview of Resident 27 was conducted. Resident 27 was observed lying in bed in his room with a blanket. Resident 27 stated the facility staff "Did not help me cut up my pancakes." Resident 27 stated he needed assistance cutting up food. During the interview, Resident 27's hands were observed. Resident 27's fingers on both hands were bent at a 90-degree angle and when asked to demonstrate, the resident was unable to fully extend and straighten his fingers. An interview was conducted on 10/30/24 at 4:32 P.M. with certified nurse assistant (CNA) 1. CNA 1 stated he worked at the facility for ten years and knew Resident 27 very well. CNA 1 stated Resident 27 was able to feed himself, however Resident 27 could not fully open both hands and at times required feeding assistance. CNA 1 stated Resident 27's fingers were bent. CNA 1 further stated that Resident 27 had bent fingers and had not been able to open his hands fully for approximately three years. During an interview on 10/31/24 at 8:54 A.M. with CNA 3, CNA 3 stated a change in a resident's condition should be reported to a licensed nurse. CNA 3 stated skin changes, refusal of care, a resident who was not eating and a change in ROM should be reported to a nurse. During an interview on 10/31/24 at 9:07 A.M. with CNA 4, CNA 4 stated a change in resident's condition should be reported to a nurse. CNA 4 stated a resident who was not eating, refusing shower, refusing therapy, a resident who was weak or unable move arms or legs were considered a change in condition. During an interview and joint record review on 10/31/24 at 3:25 P.M. with licensed nurse (LN) 3, LN 3 was asked if she had seen Resident 27's hands. LN 3 replied, "No." A joint observation on 10/31/24 at 3:25 P.M. of Resident 27 was conducted in Resident 27's room. Resident 27 showed LN 3 his hands. Resident 27 was not able to fully open both hands and had difficulty spreading his fingers. LN 3 stated Resident 27's hands were "contracted (a permanent tightening of joints preventing normal movement)." LN 3 stated Resident 27 should have a hand brace or a washcloth to maintain Resident 27's mobility. LN 3 reviewed Resident 27's care plans and stated there was no care plan regarding Resident 27's hands or resident's risk for a decline in range of motion. LN 3 further reviewed physician orders for Resident 27 and stated there was no order for rehab or restorative nursing assistant (RNA- a CNA who work alongside rehab staff to provide exercises for residents with limited mobility). An interview was conducted on 10/31/24 at 4:04 P.M. with CNA 6. CNA 6 stated Resident 27 required assistance using a spoon during meals. CNA 6 stated Resident 27 needed assistance because it was difficult for Resident 27 to hold a spoon and would eat very slow. CNA 6 stated Resident 27 did not have problems holding a spoon before but Resident 27's hands had worsened. CNA 6 stated he was unsure when Resident 27 started having difficulty holding a spoon. An interview was conducted on 11/1/24 at 8:04 A.M. with LN 5. The LN 5 stated nursing staff referred the residents to their attending physicians when a resident had trouble walking, difficulty with exercises or experienced ROM stiffness. LN 5 stated physical therapists will then assess the resident if appropriate for therapy or RNA. LN 5 further stated she was unsure of Resident 27's problems with his hands but Resident 27 was referred to rehab on 11/1/24 due to hand stiffness. An interview was conducted on 11/1/24 at 8:09 A.M. with the physical therapist (PT- focuses on improving a resident's ability to move their body) assistant (PTA). The PTA stated residents were referred to rehab on admission and from nursing report of resident change in condition. The PTA further stated all residents were screened by physical therapy on a quarterly basis for any change in condition. During an interview on 11/1/24 at 8:13 A.M. with the Director of Rehabilitation (DOR), the DOR stated a calendar was provided by the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents) for quarterly screening of residents. The DOR stated he will ask the MDSN for Resident 27's last quarterly rehab screen. The DOR stated Resident 27 was scheduled for physical therapy (PT) and occupational therapy (OT) evaluation on 11/1/24 for "Potential wrist contracture referred by the nursing staff." A joint observation of Resident 27's hands was conducted with the Director of Nurses (DON) on 11/1/24 at 8:50 A.M. The DON held Resident 27's hands and Resident 27's fingers were bent at a 90-degree angle and Resident 27 was not able to fully close both hands. Resident 27 stated his hands have been in that condition for a few months. A joint observation and interview of Resident 27 was conducted with occupational therapist (OT- a healthcare provider who helps people learn or regain skills of daily living) 1 and OT 2 on 11/1/24 at 8:55 A.M. The DON was present during the observation and interview. OT 1 attempted to straighten Resident 27's left fingers up and Resident 27 stated, "Ow." OT 1 attempted to straighten Resident 27's right fingers up and Resident 27 was not able to straighten his fingers to fully open his hand. OT 2 asked Resident 27 if he had arthritis and Resident stated, "No." OT 2 asked Resident 27 how long his hands had been in the condition it was in and Resident 27 stated, "A long time." OT 2 attempted to straighten Resident 27's fingers from a bent position and was unsuccessful. Resident 27 was also not able to spread his fingers or move the thumb up. OT 2 stated Resident 27's "hand limitations were not recent," and Resident 27 must have had the limitations for a long period of time. During an interview on 11/1/24 at 9:56 A.M. with the DOR, the DOR stated he was not able to find quarterly rehab screens for Resident 27. A call was made on 11/1/24 at 10:19 A.M. to Resident 27's attending physician to discuss Resident 27's health status. The answering service for the attending physician stated a Nurse Practitioner was covering for the physician and should return the call. There was no return call received by this writer. During an interview on 11/1/24 at 11:10 A.M. with the DON, the DON stated Resident 27's hand limitations were identified on 10/31/24 by the MDSN. During a joint record review and interview with the MDSN on 11/1/24 at 11:50 A.M., the MDSN stated an "Interdisciplinary (IDT- team members with various areas of expertise who work together toward the goals of their residents) GG (the functional abilities and goals section of the MDS) meeting" was conducted quarterly to discuss all residents' status. The MDSN stated on 7/24/24 a form titled, "IDT: Functional Abilities and Goals" was completed and indicated no impairment of Resident 27's range of motion. The MDSN stated there was no other documentation to show Resident 27's ROM status. The MDSN stated she was not aware of Resident 27's hand limitations because she had not assessed the resident. A telephone call was made by this writer on 11/1/24 at 12:57 P.M. to Resident 27's daughter who was an emergency contact according to Resident 27's Admission Record. A message was left to return call to discuss Resident 27's health status. During joint record review and interview with OT 2 on 11/1/24 at 3:11 P.M., OT 2 stated she completed an evaluation of Resident 27's hands. OT 2 stated Resident 27's joints in his hands "were fixed in flexed position and they were considered impaired. Passive ROM during evaluation caused resident to have pain and the resident was not able to perform active ROM of both hands." OT 2 stated Resident 27's carpal metacarpal joints (CMC-base of thumb where it meets the hand) on both hands were flexed at 90 degrees and could not extend. OT 2 stated Resident 27's proximal interphalangeal (PIP-joints in the finger connecting the first two bones) joints on both hands and the distal interphalangeal (DIP-hinge joints at tip of fingers) joints on both hands were in extension. OT 2 stated Resident 27 was not able to flex (bend) the joints. OT 2 further stated occupational therapy treatment for Resident 27 will be for prevention to prevent further flexion only. During an interview on 11/1/24 at 3:55 P.M. with the DON, the DON stated it was her expectation for a CNA to report a resident's change in condition to the licensed nurse. The DON stated the IDT will assess and formulate a plan of care. The DON stated it was important to identify a change in resident's condition timely to formulate a care plan with an intervention to address the change in condition. During an interview on 11/1/24 at 4:20 P.M. at the Quality Assessment and Improvement Plan (QAPI-a plan to improve the overall quality of life and quality of care and services delivered to nursing home residents) meeting with the DON, the DON stated she was not aware of the four disciplines (CNA, licensed nurse, MDS nurse and rehab staff) who missed assessing Resident 27's decline in ROM. The DON acknowledged Resident 27's decline in range in range of motion was not identified until 10/31/24. In violation of the above cited standards, the facility failed to ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion including but not limited to: preventing a decline in Resident 27's full movement potential of his hands (such as fully closing his hands to grasp or make a fist), which made it difficult for Resident 27 to cut up food items and fully grasp utensils during meals. In addition, this failure had the potential for Resident 27 to independently complete all other activities of daily living such as grooming, dressing and personal hygiene. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.