Delay in Physical Therapy Assessment Following Fall
Penalty
Summary
A resident with a history of repeated falls, dementia, schizophrenia, anxiety disorder, and major depressive disorder was not assessed by Physical Therapy (PT) in a timely manner following a fall. The resident's care plan identified significant risks for falls and wandering, and documented the need for supervision and assistance with mobility and transfers. Despite these risks and multiple falls, including an unwitnessed fall resulting in injury, there was a delay in PT evaluation after the most recent incident. Following a fall on 4/7/25, the Interdisciplinary Team (IDT) recommended a PT evaluation for an assistive device on 4/8/25, and a formal order for PT evaluation and treatment was placed on 4/11/25. However, the PT assessment did not occur until 4/17/25, which was 10 days after the fall, 9 days after the IDT recommendation, and 6 days after the order was placed. During this period, the resident continued to display impaired cognition and mobility, as observed by the surveyor, including being barefoot and unable to use the call light appropriately. Interviews with facility staff, including the PT Director and DON, confirmed that PT should have been notified and completed the evaluation as soon as possible. Both acknowledged that the delay was not in accordance with facility expectations or policy, and that timely notification and assessment are necessary. Facility policies require prompt assessment and intervention following falls, and the delay in PT evaluation was not consistent with these standards.