Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
A male resident with a history of embolism, thrombosis of the lower extremities, chronic atrial fibrillation, diabetes mellitus, hypertension, COPD, CHF, and peripheral vascular disease was admitted to the facility following hospitalization for a blood clot in his right leg. The resident, who was ambulatory prior to hospitalization, was admitted for skilled services with physician orders for physical and occupational therapy. The plan of care specified physical therapy five times per week to improve strength, balance, activity tolerance, safety, and independence with transfers, bed mobility, and ambulation. However, the resident reported not receiving physical therapy five days a week and expressed dissatisfaction with his care, stating he was not receiving the therapy needed to return home. Interviews with facility staff, including the DON and therapy staff, confirmed that the resident did not receive the ordered frequency of physical therapy sessions. The physical therapy service log showed that over a three-week period, the resident received only three therapy sessions per week, with two sessions not provided as ordered. Staff attributed the missed sessions to therapy staffing issues, including no call/no show incidents. The deficiency was identified through observation, interview, and record review, confirming the facility failed to provide specialized rehabilitative services as required for the resident admitted for skilled services.