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:
A resident who required assistance with ADLs and had moderate cognitive impairment was care planned for OT involvement and had physician orders for OT evaluation and treatment two times per week. The resident received only an initial OT evaluation, with no follow-up treatment sessions provided, and reported not recalling working with therapy staff. The rehab director confirmed the lack of ongoing OT services and noted reliance on part-time and PRN OT staff while therapy positions were being advertised.
A resident with spinal stenosis, acute kidney failure, muscle weakness, and significant ADL dependence did not receive ongoing PT/OT services because the facility failed to facilitate use of the resident’s secondary insurance after the primary insurance’s limited coverage ended. PT was discontinued after a short period and the resident was discharged to an RNA program, despite a hospital physician’s recommendation for extended PT/OT and the resident’s expressed desire and potential to benefit from more therapy. The DOR, RN supervisor, and RNA staff acknowledged the resident could have benefited from additional PT/OT, while SS and the DON were unaware that therapy had been interrupted due to insurance and that SS might be responsible for securing additional resources, contrary to facility policy requiring provision or arrangement of needed specialized rehabilitative services.
The facility failed to provide ordered speech therapy services for two residents with dysphagia and post‑cerebral infarction speech and swallowing deficits. Both had physician orders to continue existing speech therapy plans of care under a new provider, with one to receive therapy twice weekly and the other three times weekly over a defined certification period, targeting improved swallow function, diet tolerance without aspiration signs, and better communication and speech intelligibility. Medical records for each resident showed only a single 23‑minute speech therapy session during that entire period. A therapy regional manager confirmed that services under the new contractor started after the prior contractor was terminated, that these two residents received speech therapy only once, and that available telehealth speech therapy was not utilized.
A resident admitted after a fall at home with a closed head injury and transferred for rehabilitation had physician orders for OT, PT, and speech therapy evaluations and treatment that were not completed as directed. Although a wheelchair evaluation and provision occurred shortly after admission, the therapy department did not perform the ordered OT, PT, and speech evaluations within its usual 48-hour timeframe and instead scheduled them for a later date. The evaluations were never carried out because the resident was sent to the hospital for a change in mental status, and both the therapy director and DON confirmed that the physician-ordered therapy evaluations were not completed.
A resident with cancer, CHF, and COPD, who initially received PT, OT, and ST and was dependent for bed mobility and transfers, had therapy services discontinued when skilled insurance coverage ended, despite not meeting therapy goals and documented need for continued services for mobility, ADLs, transfers, cognition, communication, and dysphagia. The resident reported that therapy stopped after insurance ended, that she wanted to get strong enough to return home, and that she previously could stand and transfer with one staff but now was only transferred with a mechanical lift. Staff interviews confirmed the resident was removed from the therapy caseload due to payer changes, Part B coverage had not been verified, Medicaid was pending, nursing staff were not instructed that manual transfers were possible, and no restorative programs were in place, contrary to facility policy requiring collaboration and transition to restorative care.
Two residents admitted for rehab did not receive timely PT services in accordance with facility policy and their treatment needs. One resident with multiple serious conditions, including intracerebral hemorrhage and neurogenic bowel and bladder, remained in bed for several days after admission without PT evaluation, bariatric walker, or bariatric wheelchair, and reported having to use a urinal and have bowel movements in bed because staff did not know how the resident transferred or ambulated until PT evaluated. Another resident with hepatic encephalopathy, alcohol cirrhosis with ascites, and pancreatic cancer was not screened by PT until two days after admission and did not have a full PT evaluation and plan of care initiated until three days after admission, then received only two PT sessions before hospital transfer. The Director of Rehab reported gaps in PT staffing, lack of a full-time PT, and difficulty obtaining PT coverage, which contributed to these delays and limited therapy provision.
Failure to Provide Ordered Occupational Therapy Services
Penalty
Summary
Failure to provide specialized rehabilitative services occurred when a resident with physician orders for occupational therapy (OT) evaluation and treatment did not receive ordered OT services beyond the initial evaluation. The resident was admitted with needs for assistance with activities of daily living (ADLs) and was documented as moderately cognitively impaired on the 5-day admission MDS. The resident’s fall risk care plan included an intervention to refer to OT as needed per orders, and physician orders dated 02/24/2026 specified OT evaluation and treatment as indicated. The Director of Rehabilitation Services reported that OT was ordered two times per week and confirmed that the resident was evaluated for OT on 02/25/2026 but did not receive any subsequent OT treatments. The resident also stated he did not recall working with therapy staff while admitted. Facility staff reported that there was no full-time occupational therapist on staff and that OT coverage was being provided by a part-time weekend therapist and PRN COTAs, with ongoing efforts to recruit additional therapy staff.
Failure to Facilitate Insurance Coverage Resulting in Interrupted PT/OT Services
Penalty
Summary
The facility failed to ensure that a resident received necessary PT/OT services by not facilitating the use of the resident’s secondary insurance coverage, contrary to its Specialized Rehabilitative Services policy. The resident was admitted with diagnoses including spinal stenosis, acute kidney failure, and muscle weakness, and the MDS showed intact cognition, bilateral upper and lower extremity impairment, wheelchair dependence, and dependence on staff for ADLs. A PT evaluation and plan of treatment documented lower extremity strength deficits and the resident’s goal to walk again. PT services were provided for a limited period and then the resident was discharged to an RNA program in December, with the MDS later indicating no special treatments, procedures, or programs in the prior seven days. The resident reported that a hospital physician had recommended at least 90 days of PT/OT, but therapy was discontinued after about a month because the primary insurance only covered 32 days, despite the resident having provided secondary insurance information to the facility. The DOR confirmed that the resident could have benefited from more PT/OT and that therapy did not continue due to limitations of the primary insurance and a technical issue between the business office and the secondary insurer. The resident, RNA staff, RN supervisor, and SS director all indicated that the resident wanted more therapy and could have benefited from additional PT/OT, while SS and the DON were unaware that therapy had been interrupted due to insurance coverage issues or that SS was responsible for obtaining additional resources. The facility’s policy required it to provide or obtain specialized rehabilitative services when required by the comprehensive care plan, but this was not carried out for this resident.
Failure to Provide Ordered Speech Therapy Services
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered speech therapy services for two residents requiring specialized rehabilitative care. One resident, admitted with diagnoses including dysphagia, dementia, and rheumatoid arthritis, had an MDS indicating severe cognitive impairment and a need for supervisory support with eating, positioning, and transferring, while remaining independently mobile in a manual wheelchair. Physician orders directed continuation of the resident’s existing speech therapy plan of care under a new provider effective 02/01/26, with a treatment plan calling for speech therapy twice weekly for four weeks during the certification period 02/01/26–02/28/26. The short-term goals included tolerating a mechanical soft diet without signs or symptoms of aspiration and performing oral-motor strength exercises to improve swallow function. Record review showed only one 23‑minute speech therapy session on 02/20/26, with no other speech therapy visits documented during the certification period. The second resident, admitted with a history of cerebral infarction, dysphagia following cerebral infarction, and other speech and language deficits following cerebral infarction, had an MDS showing moderately impaired cognition, a need for supervisory support with eating, and dependence on staff for positioning and transferring, while also being independently mobile in a manual wheelchair. Physician orders similarly required continuation of this resident’s speech therapy plan of care under a new provider effective 02/01/26, with a plan of treatment specifying speech therapy three times weekly for four weeks during the same certification period. Short-term goals included improving communication and speech intelligibility and tolerating a regular texture diet without signs or symptoms of aspiration. Documentation revealed only one 23‑minute speech therapy session on 02/20/26, with no additional visits recorded. In an interview, the Therapy Regional Manager stated that rehabilitative therapy services began on 02/02/26 after termination of the previous therapy contractor, confirmed that both residents received speech therapy only on 02/20/26, and acknowledged that although telehealth speech therapy was available, it was not used.
Failure to Provide Ordered Rehabilitation Therapy Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered specialized rehabilitative services, specifically occupational, physical, and speech therapy evaluations and treatment, for one resident admitted for rehabilitation following a closed head injury. The resident was discharged from the hospital to the facility on 1/15/26 with a primary diagnosis of closed head injury and with physician orders dated 1/16/26 for OT, PT, and speech therapy evaluations and to treat as indicated. The Medical Certification for Medicaid Long-Term Care and Services and Patient Transfer Form dated 1/14/26 documented that the resident was being discharged to a skilled facility for rehabilitation. The resident’s daughter reported that her father had been hospitalized after a fall at home and that she was informed by the resident and his wife that rehabilitation therapy would not begin until 2/02/26. The Director of Therapy confirmed that although the resident was admitted with therapy orders on 1/16/26, only a wheelchair evaluation was completed on 1/16/26 and a wheelchair was provided that day. She stated that the standard practice was to complete therapy evaluations within 48 hours of admission, but in this case, the PT, OT, and speech evaluations were not performed as ordered and were instead scheduled for 2/02/26. These evaluations were not completed on 2/02/26 because the resident was sent to the hospital that day for a change in mental status. The DON confirmed that the resident had orders dated 1/16/26 for OT, PT, and speech therapy evaluations, which were acknowledged by the primary care physician on 1/21/26, and that these ordered evaluations were not completed as directed by the physician.
Failure to Continue Therapy Services After Insurance Denial
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing specialized rehabilitative services to ensure a resident maintained the highest practicable level of physical and functional mobility. The resident was admitted with malignant neoplasm of the cerebellum and right lung, congestive heart failure, and COPD, and the admission MDS showed modified independence in decision making, substantial/maximal assistance needed for toilet hygiene, and dependence for bed mobility and transfers. The resident initially received PT, OT, and ST per physician orders, and the care plan included PT/OT evaluation and treatment. OT, PT, and ST evaluations were completed, and subsequent OT and PT discharge summaries documented that the resident had not met therapy goals and would benefit from continued therapy for functional mobility, ADLs, transfers, safety, and for ongoing cognitive/communication and dysphagia needs. However, PT and ST services were discharged due to insurance exhaustion and loss of appeal, and the resident remained in the facility without further therapy. Interviews confirmed that after skilled insurance coverage ended, the resident was removed from the therapy caseload and had not received therapy services since the discharge date, while Medicaid status was still pending and Part B coverage had not yet been verified. The resident reported that therapy had stopped a few weeks earlier when insurance ended, that she had applied for Medicaid, and that her goal was to return home once she became stronger and more independent. She stated that when she was in therapy she could stand and transfer with one staff member, but currently nursing staff only used a mechanical lift and did not assist her to stand. An STNA corroborated that when the resident was on therapy she could transfer with one staff assist, but nursing staff now used a mechanical lift for all transfers and had not been informed by therapy that manual assistance was possible. The PT and Director of Rehab acknowledged that the resident would benefit from therapy, that services had been discontinued due to insurance denial, that Part B coverage had not been verified, and that the facility did not have restorative programs, despite a facility policy stating that therapy services are to help residents reach maximum functional performance and transition to restorative nursing when appropriate.
Delayed and Insufficient PT Services for Two Rehab Admissions
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services, specifically PT, in a timely manner for two residents admitted for rehabilitation. Facility policy states that therapy evaluations and services are to be scheduled and conducted in accordance with the resident’s treatment plan and Medicare guidelines, with therapy coordinated with nursing and documented in the medical record. Despite this, both residents experienced delays between admission and initiation of PT services, and therapy recommendations to nursing were not made until several days after admission for one resident. One resident was admitted with multiple serious diagnoses, including intracerebral hemorrhage, dysphagia, morbid obesity, atrial fibrillation, heart disease, neurogenic bowel and bladder dysfunction, chronic kidney disease, edema, TIA, and cognitive impairment. The admission MDS documented the resident used a walker and manual wheelchair and required substantial to maximal assistance with ADLs and was dependent for toileting hygiene, while remaining cognitively intact. The resident’s CAA noted that the resident was working with therapy for increased independence with ADLs, and staff were to provide assistance and monitor for changes. However, the EMR shows that therapy-to-nursing recommendations were not completed until four days after admission, and PT did not evaluate the resident until that date. In interview, the resident reported not being evaluated for multiple days, remaining in bed over a weekend until therapy was available, and lacking a bariatric walker and wheelchair for several days, resulting in use of a urinal and bowel movements in bed because staff did not know how the resident ambulated or transferred until PT evaluated. The second resident was admitted for rehabilitation with hepatic encephalopathy, alcohol cirrhosis with ascites, and pancreatic cancer, and the admission MDS documented the resident was cognitively intact and needed moderate assistance with bathing, dressing, and bed mobility. PT screened the resident two days after admission and identified the need for a standard wheelchair and two-wheeled walker with assistance of one staff for transfers. The PT evaluation and plan of treatment, completed three days after admission, ordered PT five times per week for four weeks, including therapeutic exercises, neuromuscular reeducation, gait training, group procedures, therapeutic activities, and wheelchair management training. Documentation shows the resident received only two PT sessions on consecutive days, with no further PT provided before the resident was discharged to the hospital. In interviews, the Director of Rehab stated there was a gap in PT staffing, that the facility did not have a full-time PT, and that she could not get a PT to come in, contributing to the delay and limited provision of PT services for this resident.
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