F688

(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

§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.

To review the impact of the physical, mental, and/or psychosocial aspects of the resident’s ability to maintain, improve or prevent avoidable decline in range of motion and mobility, the surveyor must review the provision of care and services and implementation of interventions under this tag.

INTENT §483.25(c)

To review the impact of the physical, mental, and/or psychosocial aspects of the resident’s ability to maintain, improve or prevent avoidable decline in range of motion and mobility, the surveyor must review the provision of care and services and implementation of interventions under this tag.

The intent of this regulation (F688) is to ensure that the facility provides the services, care and equipment to assure that:

• • A resident maintains, and/or improves to his/her highest level of range of motion (ROM) and mobility, unless a reduction is clinically unavoidable; and
  • A resident with limited range of motion and mobility maintains or improves function unless reduced Range of Motion (ROM)/mobility is unavoidable based on the resident’s clinical condition.

DEFINITIONS §483.25(c)

“Active ROM” means the performance of an exercise to move a joint without any assistance or effort of another person to the muscles surrounding the joint.

“Active Assisted ROM” means the use of the muscles surrounding the joint to perform the exercise but requires some help from the therapist or equipment (such as a strap).

Mobility refers to all types of movement, including walking, movement in a bed, transferring from a bed to a chair, all with or without assistance or moving about an area either with or without an appliance (chair, walker, cane, crutches, etc.).

“Muscle atrophy” means the wasting or loss of muscle tissue.

“Passive ROM” means the movement of a joint through the range of motion with no effort from the patient.

“Range of motion (ROM)” means the full movement potential of a joint.

GUIDANCE §483.25(c)

Assessment for Range of Motion:

The resident’s comprehensive assessment should include and measure, as appropriate, a resident’s current extent of movement of his/her joints and the identification of limitations, if any and opportunities for improvement. The assessment should address whether the resident had previously received treatment and services for ROM and whether he/she maintained his/her ROM, whether the ROM declined, and why the treatment/services were stopped. In addition, the assessment should address, for a resident with limited ROM, if he/she is not receiving services, the reason for the services to not be provided.

The resident-specific, comprehensive assessment should identify individual risks which could impact the resident’s range of motion including, but not limited to:

• • Immobilization (e.g., bedfast, reclining in a chair or remaining seated in a chair/wheelchair);
  • Neurological conditions causing functional limitations such as cerebral vascular accidents, multiple sclerosis, Amyotrophic Lateral Sclerosis (ALS ) or Lou Gehrig’s disease, Guillain-Barre syndrome, Muscular Dystrophy, or cerebral palsy, etc.;
  • Any condition where movement may result in pain, spasms or loss of movement such as cancer, presence of pressure ulcers, arthritis, gout, late stages of Alzheimer’s, contractures, dependence on mechanical ventilation, etc.; or
  • Clinical conditions such as immobilized limbs or digits because of injury, fractures, or surgical procedures including amputations.

Assessment for Mobility:

The resident’s comprehensive assessment should include and measure, as appropriate, a resident’s current mobility status, the identification of limitations, if any and opportunities for improvement. The MDS tool provides an assessment of the resident’s ability for movement including to and from the lying position, turning and side to side movement in bed, positioning of the body, transfers between surfaces such as to and from bed or chair, standing, and walking. The resident’s comprehensive assessment should also address whether the resident had previously received treatment and services for mobility and whether he/she maintained his/her mobility, whether there was a decline, and why the treatment/services were stopped. In addition, the assessment should address, for a resident with limited mobility, if he/she is not receiving services, the reason for the services to not be provided. In addition, the resident specific comprehensive assessment may identify individual risks which could impact the resident’s mobility including, but not limited to include the risk factors in the above section for range of motion.

Care Plan for ROM and/or Mobility

Based upon the comprehensive assessment, the resident’s care plan must include specific interventions, exercises and/or therapy to maintain or improve the ROM and mobility, or to prevent, to the extent possible, declines or further declines in the resident’s ROM or mobility. The resident/representative must be included in the development of the restorative/rehabilitative care plan and provided the risks and benefits of the treatments. The comprehensive assessment must identify the current status of the resident’s ROM and mobility capabilities, which must be used to develop interventions. The decision on what type of treatments includes an evaluation of the cognitive ability of the resident to be able to independently participate, whether the resident requires assistance due to medical condition or cognitive impairments or loss of ability to follow treatment instructions. Care plan interventions may be delivered through the facility’s restorative program, or as ordered by the attending practitioner, through specialized rehabilitative services. (Also see F825 for specialized rehabilitative services.)

Based upon the assessment, the care plan interventions must include the provision of necessary equipment and/or services necessary, adapting the environment to meet the needs of the resident, the use of equipment for bed mobility, walkers, canes, splints, braces or other rehabilitative equipment as prescribed by the attending practitioner and/or as allowed by state law, and PT/OT. Examples of interventions may include treatments such as active, passive, and/or active-assisted ROM, muscle strengthening and stretching exercises, land and/or water based activities, and/or specific physical and/or occupational therapies.

The care plan must identify the type of treatments, frequency, and duration, as well as the measurable objectives and resident goals. The measurable objectives describe what the resident is expected to achieve, such as mobility goals, and/or ROM measurements to be achieved within a specific timeframe. This enables the interdisciplinary team to determine progress including whether or not a resident has been able to maintain or increase range of motion and/or mobility. The facility must assure that the care plan provides for increasing and/or promoting independence to the extent clinically possible for the resident in the areas of both ROM and mobility. The care plan must address the presence of any contractures and interventions required, and any dependence and/or declines in mobility and ROM.

In some clinical conditions, a decline/reduction in ROM and/or mobility may occur even though the facility provides ongoing assessment, appropriate resident specific care planning and provides ongoing preventive care and interventions. Documentation must reflect the attempts made by the facility to implement the care plan and revise interventions to address the changing needs of the resident. In this type of situation, declines in ROM/mobility may be considered to be unavoidable.

The comprehensive assessment may identify specific resident risks for complications. Examples of complications that may be related to decreased ROM and/or mobility may include, but are not limited to, the following:

• • Pain;
  • Skin integrity issues;
  • Deconditioning including decreased muscle strength and atrophy;
  • Unsteady gait and balance resulting in potential falls and fractures;
  • Contractures; or
  • Respiratory and circulatory complications, such as postural hypotension, deep vein thrombosis, pneumonia; potential urinary incontinence, bowel constipation/impactions, etc.

The care plan should reflect the specific resident risks for complications and include interventions to mitigate, to the extent possible, the potential complications. If resident specific complications related to a decrease in ROM/mobility are present, the care plan must provide interventions to address the complications.

In some clinical conditions, a decline/reduction in ROM and/or mobility may occur even though the facility provides ongoing assessment, appropriate resident specific care planning and provides ongoing preventive care and interventions. Documentation must reflect the attempts made by the facility to implement the care plan and revise interventions to address the changing needs of the resident. In this type of situation, declines in ROM/mobility may be considered to be unavoidable.