HospitalInspections.org

Based on record review, policy review and interview, it was determined, the nursing staff failed to ensure interdisciplinary care plans considers patient's treatment goals with appropriate interventions. This failure affected 1 of 3 sample patients (Patient #2) as evidenced by failure to implement restorative care in a consistent basis as recommended by the therapist.


The findings included:


Clinical record review conducted on 03/26/19 revealed Patient #2 was admitted to the facility on 09/07/18 with diagnosis of respiratory failure.

Physical Therapy evaluation dated 09/11/18 documents skilled physical therapy is not indicated for Patient #2. Recommends passive range of motion to be initiated five times per week and out of bed via Hoyer lift with restorative nursing program.

Review of the interdisciplinary plan of care last revised on 03/21/19 failed to include measurable goals addressing the need of restorative services and recommendations provided by the therapist. The care plans do not provide evidence of reassessment of the patient's
restorative nursing care needs and response to nursing interventions to change or terminate the therapist recommendations.

Review of the interdisciplinary notes dated 01/01/19 thru 03/26/19 failed to provide evidence Patient #2 received restorative services five times per week as recommended.

Interview with the Physical Therapist conducted on 03/27/19 at 9 AM revealed the restorative aides work under the therapy department and they provide range of motion and get patients out of bed. Her recommendation indicated the restorative care for Patient #2.

Interview with The Chief Clinical Officer on 03/27/19 at approximately 11:12 AM revealed after review of the nurses' notes and interdisciplinary team notes, there is no evidence Patient #2 received restorative services five times per week as recommended by the therapist.

Facility policy titled "Restorative Services" dated 10/31/16 documents "Restorative services is a program provided to patients that consist of restorative, therapeutic care that can be establish by physical therapist, occupational therapist, speech therapists or registered nurses in order to maintain or meet patients' functional needs. The restorative plan for each patient is developed through a collaboration effort between nursing and therapy. Once completed, the restorative plan of care is incorporated into the nursing plan of care. Restorative program, services are provided under the supervision of a licensed nursing staff member. While providing restorative services, the tech is working under the supervision of nursing. Therefore, only the nursing presence is required during the provision of restorative services.
Criteria for restorative services included: Patients who are at very low level of function, requiring only basic exercise and or transfer out of bed to maintain the current level of functioning. They may have poor rehabilitation potential, but need regular follow up and reassessment by the therapist.
Each patient contact under restorative program will be documented in the patients' medical record by the person who provided the service."