Other·December 13, 2022

F 688 42 CFR § 483.25(c) Mobility. (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 (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. (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. 22 CCR §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: (2) Encouraging, assisting, and training in self-care and activities of daily living. (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. The California Department of Public Health (CDPH) conducted a recertification survey on 10/25/2022 to 10/28/2022. The facility failed to provide Resident 83 with appropriate services to ensure Resident 83 maintained the range of motion [(ROM)- activity aimed at improving movement of a specific joint(s)] in the right hand. The facility failed to: 1. Ensure a Restorative Nursing Aide Program (RNA, nursing aide program that help residents to maintain their function and joint mobility) service was provided to Resident 83’s right hand per Occupational Therapist [(OT), professional who provides services to increase and/or maintain a person’s capability to participate in everyday life activities] recommendations upon discharge from therapy on 10/7/2021 and 2/2/2022. 2. Ensure Resident 83 was provided with ROM services based on the Joint Mobility Evaluations (JME), which indicated Resident 83’s had a decline in right hand ROM. The Joint Mobility Assessments indicated Resident 83’s right hand ROM was at a minimal loss on 1/21/2022, and 3/31/2022, and at severe loss on 7/1/2022, and on 10/5/2022. As a result of these failures, Resident 83 lost ROM in his right hand and developed a contracture (chronic loss of joint motion associated with deformity and joint stiffness) and pain, placing the resident at risk to experience physical, emotional, and functional mobility decline. Findings: During a review of Resident 83’s Admission Record (AR), the AR indicated Resident 83, a 73-year-old-male was admitted to the facility on 9/24/2021 with diagnoses including right-sided hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following an intracerebral hemorrhage (bleeding in the brain), functional quadriplegia (inability to move due to severe physical disability or medical condition), and aphasia (loss of ability to understand or express speech, caused by brain damage). A review of Resident 83's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 9/30/2021, the MDS indicated Resident 83 had impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making and was non-verbal. The MDS indicated Resident 83 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility (moving in bed to and from different positions such as side to side), dressing, toileting, and personal hygiene, and required total assistance (full staff assistance) from staff for transfers (moving from one surface to another such as a bed or chair), eating, and bathing. The MDS indicated Resident 83 had functional limitations in ROM on one arm (shoulder, elbow, wrist, hand), and both legs (hip, knee, ankle, foot). A review of a document titled, "Occupational Therapy HMO Evaluation and Plan of Treatment" (OT Evaluation), dated 9/26/2021, indicated Resident 83 had the right-hand ROM within normal limits (WNL, no joint mobility limitations) and did not have the strength to move the right hand independently. A review of Resident 83's OT Discharge Summary, dated 10/7/2021, indicated OT recommended Resident 83 to have an RNA program upon discharge from occupational therapy to maintain current function and joint mobility. During a review of Resident 83's physician's orders, there was no physician’s order (PO) for Resident 83 to have RNA services as recommended by OT on 10/7/2021. A review of Resident 83's quarterly JME, conducted by the MDS nurse, dated 12/20/2021, indicated Resident 83's right hand and fingers’ ROM were within functional limits (WFL, sufficient joint movement to functionally complete daily routines) with 1-25% ROM impairment. The Joint Mobility Limitation Key on the JME form indicated WFL limitation represented "variance (decline) due to normal aging process allowed up to 25%." The JME’s ‘Additional Comments’ section was blank. A review of Resident 83's JME conducted by a Physical Therapist [(PT)-a movement expert who improves quality of life through prescribed exercise, hands-on care, and patient education] dated 1/21/2022, indicated Resident 83's right hand and fingers had minimal ROM limitations (26-50% ROM impairment). The JME Additional Comments specified the resident's right hand had a contracture, which was indicative of a decline since the prior ROM evaluation on 12/20/2021. A review of Resident 83's POs, dated 1/27/2022, indicated an OT evaluation was ordered. A review of the “OT Evaluation,” dated 1/28/2022, indicated Resident 83's right hand ROM was "impaired" with minimal swelling. A review of Resident 83's OT Discharge Summary, dated 2/2/2022, indicated OT recommended Resident 83 to have an RNA program upon discharge from occupational therapy. During a review of Resident 83's POs, there was no PO for Resident 83 to receive RNA services as OT recommended on 2/2/2022. A review of Resident 83's quarterly JME conducted by a PT, dated 3/31/2022, indicated Resident 83's right hand and fingers had minimal ROM limitations (26-50% ROM impairment). Additional comments indicated, "Passive Range of Motion" (PROM- movement at a given joint with full assistance from another person)." A review of Resident 83's quarterly JME conducted by a PT, dated 7/1/2022, indicated Resident 83's right hand and fingers had severe ROM limitations (76-100% ROM impairment). The JME’s Additional comments section was blank. During a review of Resident 83's POs, dated 7/7/2022, a PO indicated the order for RNA to perform PROM to both arms and both legs three times per week as recommended by the Rehabilitation department. A review of Resident 83's RNA documentation, from 7/2022 to 10/2022, indicated an RNA provided PROM to both of Resident 83's arms and both legs three times per week with the start date on 7/8/2022. A review of Resident 83's quarterly JME conducted by an OT, dated 10/5/2022, indicated Resident 83's right hand and fingers had severe ROM limitations (76-100% ROM limitations). During a review of Resident 83's POs, dated 10/26/22, a PO indicated the order for OT evaluation and treatment. A review of a document titled " OT Evaluation,” dated 10/27/2022, indicated Resident 83 was referred to OT due to " decrease in strength and decrease in ROM especially right-hand, causing change in [activities of daily life] participation related to risk of contracture." The evaluation listed measures to implement "(to prevent) right hand contracture." The OT Evaluation indicated the ROM of all fingers of Resident 83's right hand was "impaired" and included the following assessments: 1. Right thumb interphalangeal (IP, joint below the fingernail of the thumb) extension (straightening the joint): 0-30 degrees (30-degree range, normal range is 0-80 degrees). 2. Right index finger proximal interphalangeal (PIP, joint of the finger in between the fingertip joint and the large knuckle joint) PIP extension: 80-90 degrees (10-degree range, normal range is 0-100 degrees). 3. Right middle finger PIP extension: 80-90 degrees (10-degree range, normal range is 100 degrees). 4. Right ring finger PIP extension: 80-100 degrees (20-degree range, normal range is 100 degrees). 5. Right little finger PIP extension: 70-80 degrees (10-degree range, normal range is 100 degrees). The OT Evaluation further indicated the treatment plan of skilled therapeutic intervention, including ROM and splints to the right hand to address ROM loss and developing right hand contracture. The OT Evaluation date was changed from 10/26/2022 to 10/27/2022 by the OT. During an interview on 10/26/2022, at 1:29 PM, the Director of Rehabilitation (DOR) who is an OT, stated she performed an OT evaluation on Resident 83 earlier that day. The DOR stated she recommended a skilled therapy program and right-hand splints due to right hand ROM loss and high risk for contracture development. The DOR stated she called the physician and ordered a right-hand splint for Resident 83. The DOR stated therapists refer residents to an RNA program once they were discharged from skilled therapy to maintain their function and mobility. The DOR stated the referring therapist completed a document called the “Restorative Assessment/Referral” to transition residents to an RNA program after residents were discharged from therapy. The completed document was given to the charge nurse who then entered the RNA order in the electronic documentation system. Once the RNA order was entered, the Restorative Assessment/Referral form was placed in a white binder which was stored in the Rehabilitation Department. During a concurrent interview and record review of Resident 83's OT’s Evaluations (9/26/2021, 1/28/2022, and 10/27/2022) and JMEs (12/20/2021, 1/21/2022, 3/31/2022, 7/1/2022, and 10/5/2022) with the DOR on 10/28/2022, at 9:30 AM, the DOR confirmed Resident 83 was admitted to the facility with normal right-hand ROM. The DOR confirmed OT Discharge Summaries on 10/7/2021 and 2/2/2022 recommended an RNA program at the time of discharge from the occupational therapy to maintain Resident 83's current level of function. The DOR stated an RNA program should have been ordered on 10/7/2021 and 2/2/2022 based on OT discharge recommendations. The DOR confirmed there was only the RNA order in Resident 83's medical record dated 7/7/2022. The DOR confirmed Resident 83's JMEs showed a progressive increase in right hand ROM limitations on 1/21/2022 (minimal limitations), 3/31/2022 (minimal limitations), 7/1/2022 (severe limitations), and 10/5/2022 (severe limitations). The DOR confirmed the last OT Evaluation performed was on 1/28/2022. The DOR stated an OT’s evaluation should have been ordered when ROM loss was identified but was not ordered again until 10/26/2022. During a concurrent observation and interview on 10/28/2022, at 1:14 PM, in Resident 83's room with DOR present, Resident 83 was lying in bed with his right arm resting on a pillow. Resident 83's right hand appeared to have minimal swelling and was positioned in a tight fist with the thumb tucked inside the palm. Resident 83 was awake, non-verbal, and had difficulty following simple instructions. The DOR was unable to unclench Resident 83's right hand and had difficulty measuring the finger lengths due to Resident 83 experiencing pain. Resident 83 was grimacing, moaning, grunting, and reached across his body with his left arm several times to try to stop the DOR from continuing right-hand ROM. The DOR stated Resident 83 appeared to be in pain and annoyed with ROM attempts. The DOR stated Resident 83's right hand felt very stiff, the fingers could not be straightened, and the PIP joints of all the fingers had a hard end feel (felt hard/stiff at the end of the joint range). During a concurrent interview and record review of Resident 83’s POs and RNA flowsheets (7/2022 to 10/2022) with the Director of Nursing (DON) on 10/28/2022, at 2:23 PM, the DON stated there were no RNA orders and no RNA flowsheets for Resident 83 prior to 7/7/2022. The DON stated Resident 83 did not receive RNA services until after 7/7/2022 (9 months after the first OT recommendation for RNA dated 10/7/21) as RNA was not allowed to provide services without a physician's order. During an interview on 10/28/22, at 2:33 PM, Restorative Nursing Aide 2 (RNA 2) and RNA 3 stated they began right hand ROM exercises with Resident 83 in 7/2022. RNA 2 and RNA 3 stated Resident 83's right hand was held in a fist and felt very stiff. RNA 2 and RNA 3 stated Resident 83 did not tolerate right hand ROM exercises well due to pain and they had not been able to straighten Resident 83's fingers since RNA services began in 7/2022. During an interview on 10/28/2022, at 2:45 PM, the DOR stated there was no Restorative Referral/Assessment form for Resident 83. The DOR stated Resident 83 was not transitioned to RNA upon discharge from OT if a Restorative Referral/Assessment form was not completed. The DOR stated monthly meetings with RNA were recently implemented "so that no one gets missed like this." During a concurrent interview and record review of Resident 83’s OT’s evaluations (9/26/2021, 1/28/2022, and 10/27/2022), JMEs (12/20/2021, 1/21/2022, 3/31/2022, 7/1/2022, and 10/5/2022) and physician’s orders on 10/28/2022, at 5:15 PM, the DON stated the decline in Resident 83's right hand ROM could have been avoided if the appropriate ROM services were provided. The DON confirmed Resident 83 was admitted to the facility with no right-hand ROM limitations. The DON confirmed Resident 83 developed significant right hand ROM loss since admission due to lack of ROM services. The DON confirmed Resident 83 did not receive RNA services in accordance with OT discharge recommendations for RNA program on 10/7/2021 and 2/2/2022. The DON stated OT should have evaluated Resident 83 once the JMEs identified a decline in right hand ROM from minimal to severe (7/1/2022 and 10/5/2022). During a review of the facility's policy and procedure (P/P) titled, "Resident Mobility and Range of Motion," revised on 7/2017, the P/P indicated the 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 a further decrease in ROM. The P/P indicated the interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. During a review of the facility's P/P titled, "Resident Mobility and Range of Motion," revised on 7/2017, the P/P indicated the residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The P/P indicated the care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. The facility failed to provide Resident 83 with appropriate services to ensure the resident maintained the range of motion (ROM) in the resident’s right hand. The facility failed to: 1. Ensure a Restorative Nursing Aide Program (RNA, nursing aide program that help residents to maintain their function and joint mobility) service was provided to Resident 83’s right hand per Occupational Therapist [(OT), professional who provides services to increase and/or maintain a person’s capability to participate in everyday life activities] recommendations upon discharge from therapy on 10/7/2021 and 2/2/2022. 2. Ensure Resident 83