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F0825
D

Failure to Provide Timely Rehabilitative Therapy Evaluations

Novato, California Survey Completed on 04-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide specialized rehabilitative services as required for a resident with quadriplegia and bipolar disorder. Despite a physician's order dated 11/29/23 for evaluations in physical therapy (PT), occupational therapy (OT), and speech therapy (ST), these evaluations were not completed within the required 24 to 72 hours. The resident reported that the facility refused to evaluate him for these therapies for several months, which was confirmed by the absence of documentation for timely PT, OT, and ST evaluations. The only OT evaluations on file were conducted months after the physician's order, and there was no documentation of an ST evaluation or a waiver to justify its absence. The facility was also unable to provide evidence that the physician was notified about the delay or reasons for not completing the evaluations as ordered. Interviews with facility staff revealed that the expectation was for therapy evaluations to be completed within 24 to 72 hours of a physician's order. The Director of Nursing and Director of Rehabilitation both acknowledged the lack of documentation and the absence of a facility policy on rehabilitation services. Additionally, a witness reported that a physical therapist dismissed the physician's order, stating it was unnecessary and that the resident would not benefit from therapy. This lack of action resulted in the resident not receiving the ordered rehabilitative services for an extended period.

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