CMS SOM App. PP, Tag F688

§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.

Administrative Review

The facility must develop resident care policies in collaboration with the medical

director, director of nurses, and as appropriate, physical/occupational therapy consultant.

This includes policies on restorative/rehabilitative treatments/services, based on

professional standards of practice, including who may provide specific treatments and

modalities according to applicable State law and/or practice acts. Refer to F841, Medical

Director. These policies should also address equipment use, cleaning, and storage.

In situations where the survey team has concerns related to patterns or widespread

noncompliance within the requirements for Mobility, please see guidance at §483.75,

QAPI/QAA.

KEY ELEMENTS OF NONCOMPLIANCE

To cite deficient practice at F688, the surveyor's investigation will generally show that

the facility failed to provide treatment/services, equipment, supplies and/or assistance to:

• Prevent an avoidable reduction of ROM and/or mobility in residents admitted

with full ROM and/or mobility status; or

• Increase ROM or mobility status or prevent further avoidable reduction of ROM

and mobility; or

• Maintain or improve ROM/mobility.

INVESTIGATIVE SUMMARY

Use - Use the Positioning, Mobility & Range of Motion (ROM) Critical Element (CE)

Pathway, along with the above interpretive guidelines when determining if the facility

provides the necessary care and services to meet the resident’s needs.

Summary of Procedure

Briefly review the most recent comprehensive assessments, comprehensive care plan and

orders to identify whether the facility has assessed and developed an individualized care

plan based on professional standards of practice and provided by qualified, competent

staff. During this review, identify the extent to which the facility has implemented

interventions in accordance with the resident’s needs, goals for care and professional

standards of practice, consistently across all shifts. This information will guide

observations and interviews to be made in order to corroborate concerns identified.

NOTE: In addition to actual or potential physical harm, always observe for visual cues

of psychosocial distress and consider whether psychosocial harm has occurred when

determining severity level (See guidance on Severity and Scope Levels and Psychosocial

Outcome Severity Guide located in the Survey Resources zip file located at

https://www.cms.gov/medicare/provider-enrollment-and-

certification/guidanceforlawsandregulations/nursing-homes).