Failure to Initiate Ordered Therapy Services After Resident Fall
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for a resident following a fall that resulted in acute right posterior rib fractures. The resident, who had a history of hypertension, COPD, diabetes mellitus, and muscle weakness, experienced a fall in her room and subsequently complained of pain in her left shoulder, ankle, and ribs. Despite a physician's order for both physical therapy (PT) and occupational therapy (OT) evaluations and treatment due to increased pain, the clinical record showed that OT services were never initiated and PT services were not started until several weeks after the order was given. Documentation confirmed that the staff notified therapy of the new order, but there was no evidence that OT was ever provided, and PT was delayed significantly. Interviews with facility leadership verified that the staff did not follow the physician's orders according to facility protocol, and there was no policy in place regarding the timely processing of such orders. The failure to initiate therapy services as ordered constituted a deficiency in providing required specialized rehabilitative services.