Failure to Communicate and Implement OT Referral After Orthopedic Surgery
Summary
A facility failed to communicate and implement an Occupational Therapy (OT) referral ordered by an Orthopedic Surgeon for a resident who had undergone open reduction internal fixation (ORIF) surgery for a right olecranon fracture. The OT referral, which included instructions for range of motion (ROM), pain and edema control, a home exercise program, and splint removal for hygiene and active ROM, was not relayed to the therapy department. The referral order was scanned into the resident's electronic health record under a different tab from other orthopedic information, resulting in it not being reviewed or acted upon by nursing or therapy staff. The resident, who had severe cognitive impairment and required maximal assistance with upper body dressing and personal hygiene, did not have her splint removed or receive OT evaluation and treatment as ordered. The splint remained in place for nearly two months, and the resident was not evaluated by OT until over three months after the initial referral. During this period, the resident developed two pressure ulcers on the right elbow, one of which exposed surgical hardware and became infected, ultimately requiring surgical intervention for hardware removal and intravenous antibiotics for MRSA. Interviews with facility staff, including the DON, Therapy Director, and Medical Director, confirmed that the OT referral was not communicated or implemented due to breakdowns in the process for handling outside provider orders and documentation. The Orthopedic Surgeon and Therapy Director both stated that the resident should have received OT services as ordered, and the lack of therapy and splint removal contributed to the development of pressure wounds and infection. The deficiency affected one resident reviewed for therapy and resulted in significant harm.
Removal Plan
- Administrator and Director of Clinical Services reviewed all resident orders with outside appointments to ensure they were in place and correct.
- Therapy Director completed an audit of all current facility residents with therapy orders to ensure the correct physician ordered treatment was in place.
- Ad Hoc QAPI meeting conducted to review and determine root cause of the deficient practice.
- Education implemented on who will be responsible for ensuring the referral form is brought back to the facility when a resident has an outside appointment so new recommendations or orders can be implemented.
- Unit Manager will be responsible for ensuring the referral form returns with the resident; if it is the weekend or after hours, the hall nurse will be responsible.
- Transporter will notify the Unit Manager the resident is back from the appointment and will give her any paperwork at that time.
- If there is no referral form, the Unit Manager will call the physician office to obtain a copy of the form.
- Director of Clinical Services provided education to the Administrator, DON, Transportation driver and ADON on new procedures for handling outside appointment paperwork and therapy referrals.
- Unit manager, or designee, will be responsible for entering orders and ensuring any therapy referrals are received by therapy.
- DON will have a list of resident appointments and will follow up with the Unit Managers to ensure all referral forms have been returned and reviewed, with any new orders entered into the medical record.
- Nurse Aides that accompany a resident to an outside appointment are there to care for the resident; the Transportation Driver will be responsible for ensuring any paperwork, and the referral form, are returned to the Nurse Manager or hall Nurse.
- Unit Manager was educated that when a family member signs the resident out for an outside appointment, they are to follow up with the family when they sign the resident back into the facility to ensure all paperwork has been given to the nurse for review.
- Unit Managers, or designee, will be responsible for taking any therapy referral orders for new admissions to the therapy department on the day of admission.
- DON and ADON provided education to all facility Licensed Nurses and Nurse Aides on new procedures for handling outside appointment paperwork and therapy referrals.
- Current facility Licensed Nurses and newly hired nurses not received education will not be allowed to work until the education has been completed.
- DON will utilize an active employee list to track completion of education and validate the post education written test was completed and passed.
- Education will also be included during orientation for newly hired facility Licensed Nurses, Nurse Aides, and Transportation drivers, to be completed by Director of Nursing or Nurse Manager.
- Administrator and Director of Nursing will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged noncompliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to provide ordered PT services for a resident with TBI and severe cognitive impairment. The resident had repeated specialist recommendations for PT, OT, and ST, including ROM and therapy at max allotted intervals, but the record showed no PT screen, eval, or treatment for more than 6 months after the request was approved by the PA. The Rehab Director acknowledged the resident had not received PT since the prior year, and the Administrator and DON could not provide evidence of the ordered rehab services.
Therapy Evaluations Not Completed as Ordered: A resident admitted with PT and OT orders filed a grievance after reporting he had gone a week without therapy. Staff said the resident refused therapy, but the EHR had no refusal documentation until after the grievance, and therapy records showed no entries before that time. The DOR stated the evals were delayed because of refusals and that documentation could not be entered until an eval was opened.
A resident admitted after a fractured leg surgery did not receive ordered PT/OT despite being alert, oriented, and able to participate in rehab. The resident remained dependent for transfers and mobility, had ongoing left leg wounds with multiple dressings, and reported weakness, recurrent infections, fear, anxiety, and depression because therapy never started. The therapy director, administrator, and business office manager acknowledged the facility did not follow up on payer authorization, and the chart showed no PT/OT services or restorative nursing program were initiated.
A resident with dysphagia and significant neuro diagnoses had physician orders for PT, OT, and ST screening on admission, but the therapy dept did not complete the requested evals before discharge. The resident’s chart lacked evidence of a BIMS during the stay, and staff interviews showed the resident was placed on a communication board for ST screening/swallow eval but was not seen in time. Facility policy required therapists to screen all new admits and include specialized rehab services in the admission process.
A resident with hemiplegia, HTN, and DM had an ordered restorative nursing program for ROM, stretching, and strengthening exercises to maintain function. Survey review found the program was repeatedly missed or only partially completed over several months, and interviews showed the restorative aide was the only aide covering the whole building, could not always complete all residents’ programs, and staff were unclear who covered when she was unavailable.
A resident with hemiplegia, hemiparesis, aphasia, and dysphagia after a CVA was admitted with orders to continue PT, OT, and ST, but the therapy screening was marked not indicated. The DOR said she was unaware of the therapy orders, the resident’s daughter emailed that therapy had not started, and the DON stated the discharge order to continue therapy was missed, delaying the resident’s rehab services.
Failure to Provide Ordered PT Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services for one resident with a history of traumatic brain injury. The resident was admitted in December 2024 and had a Quarterly MDS showing a BIMS score of 4 of 15, indicating severe cognitive impairment, with dependence on staff for bed mobility and transfers. A Continuity of Care Consultation and Referral Form from a university medicine and rehabilitation provider dated 1/27/2026 recommended resuming PT and OT, and a nursing progress note the same day showed the recommendation was reviewed and approved by a PA. Additional consultation forms dated 3/31/2026, 5/21/2026, and 6/30/2026 continued to recommend PT, OT, and ST, including ROM to the bilateral upper and lower extremities and therapy at the maximum allotted intervals at the facility. Record review did not reveal evidence of a PT screen, evaluation, or treatment after the January 2026 request, and the resident had gone more than 6 months without the recommended rehabilitative services. A PM&R physician note dated 6/30/2026 stated that PT/OT/ST were strongly recommended at the maximum allocated intervals due to ongoing functional gains. During interviews, the PA stated she approved the therapy recommendations and expected staff to follow specialist recommendations. The Rehab Director acknowledged the resident had not been evaluated or treated by PT since December 2025 and knew PT had been requested several times since January 2026. The Administrator and DON were unable to provide evidence that the resident received the specialized rehabilitation services after approval.
Therapy Evaluations Not Documented or Completed as Ordered
Penalty
Summary
The facility failed to ensure specialized rehabilitative services were provided as ordered for Resident 24, who was admitted on [DATE] with hospital transfer orders dated 07/01/2026 for PT and OT. The resident filed a grievance on 07/07/2026 stating he had been in the facility for a week without receiving therapy services. Facility staff documented in the grievance log that the PT and OT evaluations had not yet been completed because the resident had refused therapy several times, but the electronic health record contained no documentation of therapy refusals until after the grievance was filed. A nurse’s note on 07/07/2026 documented that the resident expressed frustration about being in a rehabilitation center and not receiving therapy, and therapy staff reported the resident had refused therapy and would be reapproached the next day. When records were later requested, the facility provided therapy documentation showing no entries prior to 07/08/2026. The Administrator stated he had been told by the DOR that the resident was refusing all therapy, and the DOR reported the evaluations were not completed during the first week because of refusals. The DOR also stated the refusals were not documented because therapy staff could not enter information into the therapy program until an evaluation was opened, and the evaluations could not be opened because the resident had refused them.
Failure to Initiate Ordered Rehab Services
Penalty
Summary
The facility failed to ensure physician-ordered rehabilitation services were implemented and monitored for one resident who was admitted after a left lower extremity fracture requiring surgery and who also had cellulitis of the left lower limb, type 2 diabetes mellitus, morbid obesity, chronic venous insufficiency, chronic diastolic heart failure, osteoporosis, a muscle disorder, and complex regional pain syndrome of the left lower extremity. The resident’s MDS documented that she was cognitively intact and required extensive assistance or dependence with toileting, showering, and transfers. During observation, she was seated in a motorized wheelchair with blankets positioned around the chair and had five undated occlusive dressings on her left lower extremity. The resident stated she had been admitted for physical therapy after surgery for her fractured left leg but had never received therapy since admission, despite continued weakness and recurrent infections in the left leg. She reported remaining dependent on staff for transfers and mobility and said she felt fearful about possibly losing her leg and anxious and depressed about not regaining function or returning home because she was not getting the therapy she needed. The therapy director stated the resident had not received therapy services since admission, although an OT evaluation had been completed and requests for payer authorization had been sent. The facility had no evidence that PT or OT had been initiated and no documentation of a restorative nursing program or other interventions while awaiting authorization. The administrator and business office manager acknowledged the authorization request had not been followed up, and the physician stated he had ordered PT and OT because the resident was alert, oriented, and capable of participating in rehabilitation to improve strength, prevent decline in ADLs, and promote healing of the left leg wounds.
Failure to Complete Ordered Rehab Screening on Admission
Penalty
Summary
The facility failed to ensure physician-ordered PT, OT, and ST screening on admission was completed for one resident. The resident had diagnoses including dysphagia, nontraumatic subarachnoid hemorrhage from the anterior communicating artery, obstructive hydrocephalus, and cerebral infarction due to unspecified occlusion or stenosis of the left posterior cerebral artery. The resident was admitted to the facility and later discharged, and the electronic medical record did not show a BIMS during the stay. The Physician Order Sheet dated 6/16/26 included orders for PT, OT, and ST screen on admit, readmit, and/or as needed, with evaluation and treatment if applicable. The care plan dated 6/17/26 documented dysphagia interventions including speech therapy as ordered to evaluate and treat as indicated. The hospital record dated 6/16/26 documented discharge needs based on assessment and noted therapy needs at discharge as intensive daily therapy, five or more times per week. During interviews, the therapy manager stated the therapy department did not evaluate the resident while she was at the facility and was unsure why the resident was not seen. She stated residents admitted with dysphagia, a G-tube, and an oral diet should be evaluated by ST upon admission due to aspiration risk. The SLP stated the resident’s name appeared on the communication board for screening and swallow evaluation, but when she attempted to access the chart she learned the resident had already discharged. The facility policy required therapists to screen all new admits and included specialized therapists in the preadmission process to ensure timely assessments and services were offered.
Failure to Provide Ordered Nursing Rehab Services
Penalty
Summary
The facility failed to provide nursing rehab services as ordered for one resident with intact cognition, left-sided hemiplegia, hypertension, and diabetes. The resident’s care plan directed staff to follow the nursing rehab program, and discharge and rehab follow-up recommendations identified a maintenance program that included self-range of motion, passive range of motion, stretching, and use of a seven-pound dumbbell or power web flex gripper three times a week to maintain strength and ROM in the left upper and lower extremities. Documentation showed the ordered restorative program was not completed as scheduled. The survey review found repeated gaps in both the dumbbell/gripper exercises and ROM program across February, March, April, May, June, and July 2026, with multiple weeks showing fewer than three completed sessions and some weeks showing no ROM completion at all. The resident stated the restorative nursing aide came to work on his arms, but the resident believed the exercises were occurring only once a week even though they were ordered more often. Interviews showed the restorative program was not consistently covered when the restorative nursing aide was unavailable. The restorative nursing aide stated she was the only restorative aide, was responsible for the whole building, and could not always see all residents each day because of appointments, activities, or residents staying in bed. She was unsure who covered restorative when she was off. The RN clinical coordinator was unaware who completed restorative programs when the restorative aide could not see all residents, and the DON stated that when the restorative aide was not working, the programs were supposed to be triggered for nursing assistants to complete. The DON reviewed the documentation and confirmed the restorative programs were not being done as ordered for the resident.
Missed ordered therapy services for a resident with stroke-related deficits
Penalty
Summary
The facility failed to ensure that a resident received specialized rehabilitative services as ordered. Resident #2 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, aphasia, and dysphagia. The hospital discharge instructions for the admission to the facility stated that the resident was to continue the therapy program, and the resident’s progress notes showed an encounter with the Family Nurse Practitioner the day after admission. The record also reflected that the resident was admitted for continued physical therapy, occupational therapy, and speech therapy. The admission therapy screening completed on the day of admission indicated that therapy was not indicated. The Director of Rehabilitation stated she was not aware the resident had therapy orders and therefore marked the screening as not indicated. She also stated the resident’s daughter had emailed the therapy department that the resident was supposed to receive therapy but had not. The DON stated the hospital discharge orders were reviewed upon admission and the order to continue therapy at the facility was missed. The Director of Rehabilitation further stated the resident’s therapy start was delayed because she was unaware of the order for therapy upon admission.
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