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 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.
Failure to identify a decline in ADLs and mobility delayed consideration of renewed rehab services for a resident with generalized muscle weakness, morbid obesity, and bilateral knee OA. After OT/PT discharge at maximum potential, later MDS assessments showed the resident still needed substantial to maximal assistance for toileting hygiene and bed mobility, but the RC was not notified of the decline and the DON stated there was no documentation that the physician was notified to consider new PT/OT evaluations.
Failure to provide quarterly therapy screening for a resident with DM2, COPD, CHF, CKD, and anxiety. The resident’s care plan called for routine therapy screening, evaluation, and treatment as ordered, but after PT/OT ended due to lack of progress and participation, the resident was not re-evaluated for therapy services. The resident reported arm weakness from being in bed and said he could use therapy, and the DTR confirmed no therapy evaluation had occurred since discharge despite the expectation for quarterly screens.
A resident with quadriplegia, DM, and COPD was ordered RNA passive ROM for all 4 extremities 4 times weekly, but restorative records showed multiple blank days and inconsistent entries for provision or refusal of care. The resident said RNA helped maintain movement, while RNA staff and the DON stated that every session or refusal should be documented in PCC to validate the service was done.
A resident with dementia, CKD, COPD, urinary retention, edema, and unsteadiness had a physician order for OT to evaluate decreased ability to feed herself, but no documented OT evaluation was completed. The family and legal guardian raised concerns about communication and feeding ability, the DON emailed OT to request the eval, and the DOR later stated the resident was delayed behind new admissions without informing the family, Administrator, or DON.
Failure to provide ordered PT/OT services for two residents. One resident had a physician order for PT for declined ADLs, but no PT eval or treatment was documented and therapy staff were unaware of the order. Another resident had repeated APRN orders for PT/OT consults for offloading needs and a properly fitted pressure-relieving cushion, but no PT/OT consult or evaluation was completed or documented.
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.
Failure to Identify Decline for Rehabilitative Services
Penalty
Summary
Provide or get specialized rehabilitative services as required for a resident was not ensured for one resident after a decline in ADLs and mobility. The resident had diagnoses of generalized muscle weakness, morbid obesity, and osteoarthritis of both knees. Her MDS showed she was independent in daily decision making but required substantial to maximal assistance for showering, bathing, toileting hygiene, rolling side to side in bed, and moving from lying to sitting. She had previously received OT and PT from 10/7/2025 to 12/11/2025, and both therapy discharge summaries stated she had achieved her maximum potential at discharge, with improvement to standby assistance for hygiene and grooming and standby assistance for rolling in bed, and minimal assistance for moving from lying to sitting. Later MDS assessments showed the resident continued to require substantial to maximal assistance for toileting hygiene and for rolling and moving from lying to sitting in bed. During interview, the RC stated she was not notified of the resident’s decline in hygiene tasks or mobility identified in the MDS assessments, and stated prompt notification was important so interventions could be implemented. The RC also stated that if there were a decline after therapy discharge, the resident would have benefited from renewed services and the physician could have been notified to determine whether new PT and OT evaluations were appropriate. The DON stated there was no documentation that the physician was notified of the resident’s decline in ADLs and mobility, and stated staff should have notified the physician so the care plan could be revised and the change in condition addressed.
Failure to Provide Quarterly Therapy Screening
Penalty
Summary
The facility failed to provide quarterly screening for therapy services for one resident. Resident #7 was admitted with diagnoses including Type II diabetes, COPD, chronic diastolic heart failure, unspecified anxiety disorder, and unspecified chronic kidney disease. The most recent MDS showed the resident was cognitively intact, had no behaviors, did not wander, and frequently rejected care. The care plan stated the resident required assistance with ADLs and included interventions for therapy to screen routinely, evaluate, and treat as ordered. The resident received PT and OT from 09/23/25 to 10/16/25 and was discharged because of lack of progress and lack of compliance/participation in therapy. During an interview, the resident stated his arms were getting weaker from being in bed and that he could use therapy. The Director of Therapy Services confirmed the resident had not been evaluated for therapy services since discharge in October 2025 and stated each resident was supposed to be screened quarterly. The facility policy also stated quarterly facility-wide screens were conducted to identify residents who might benefit from skilled therapy.
Incomplete Documentation of Restorative Nursing ROM Services
Penalty
Summary
The facility failed to ensure that Restorative Nursing Session (RNS) services were performed according to physician orders and the facility’s Resident Restorative Nursing Program Guidelines for one resident. The resident was admitted with diagnoses including quadriplegia, DM, and COPD, and the MDS indicated the resident was cognitively intact and dependent on staff for ADL care. The physician orders dated 1/27/2026 directed RNA program passive ROM exercises for the left lower extremity, right lower extremity, left upper extremity, and right upper extremity four times a week as tolerated. During interview, the resident stated he was unable to get out of bed, had limited mobility, and received RNA to help maintain movement and prevent further decline. Review of the restorative documentation for 3/2026 through 6/2026 showed multiple blank entries and inconsistent documentation of service provision or refusal. The entries included notations such as 15 minutes with resident encouragement, passive participation, and refusals, but many scheduled days had no documentation at all. RNA staff stated that blank documentation meant nothing was done and that every encounter, whether services were provided or refused, should be documented in the chart. The DON stated the facility expected RNAs to document when services were provided or not, and that documentation should occur as soon as able during the shift to validate the service was done. The DON also stated that a blank in the documentation or lack of a progress note indicated a task was not done. The facility’s policy stated that the RNA will document each session, including the type of activity performed, frequency/duration, level of assistance provided, and resident response and tolerance.
Failure to Complete Ordered OT Evaluation for Feeding Ability
Penalty
Summary
The facility failed to evaluate a resident for occupational therapy services as required by a physician’s order. Resident #146 was admitted with diagnoses including unspecified dementia, chronic kidney disease stage 4, chronic embolism and thrombosis, COPD, shortness of breath, retention of urine, localized edema, and unsteadiness on feet. A quarterly MDS documented severely impaired cognition with a BIMS score of 3, maximal assistance needed for eating, oral hygiene, upper body dressing, and footwear, dependence for toileting, bathing, and personal hygiene, an indwelling urinary catheter, frequent bowel incontinence, and recent anticoagulant use. After the resident’s family member and legal guardian raised concerns about communication with the medical team and the resident’s ability to feed herself, the facility documented that an order was placed for OT to evaluate her ability to feed herself. The physician’s order directed OT to evaluate for decreased ability to feed self, but the record contained no documented evidence that OT completed the evaluation after the family meeting and order. The DON emailed OT requesting the evaluation, and the Director of Rehabilitation Services later stated the resident was placed on a list for OT evaluation but was pushed down behind new admissions and the family, Administrator, and DON were not informed.
Failure to Provide Ordered PT/OT Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered for two residents reviewed for therapy services. The facility policy stated that rehabilitative services are to be provided in accordance with assessment results, the comprehensive plan of care, and physician orders, and that a qualified therapist should evaluate the resident and develop a plan of care within the required timeframe after the physician’s order. For one resident, the record documented a physician order for physical therapy for declined ADLs, but the electronic health record did not show a PT evaluation or treatment, and the occupational therapist stated the resident had not received PT and the therapy department was not aware of the order until the surveyor interview. For a second resident, wound assessment and treatment orders repeatedly documented a recommendation for PT/OT for offloading needs and a properly fitted pressure-relieving cushion, but the record did not show a PT/OT consult or evaluation for the offloading needs or cushion. The physical therapist stated the resident had not had a PT or OT consultation and was not aware of the order, and the APRN stated she had been asking for PT/OT consultation for about two weeks and was not aware it had not been done.
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