Failure to Provide Occupational Therapy as Ordered
Penalty
Summary
The facility failed to provide occupational therapy (OT) treatments five times a week as required by the OT plan of treatment and care plan for one resident. The resident, who was admitted with muscle wasting, atrophy, and a right humeral neck fracture, had moderate cognitive impairments and significant functional limitations, including dependence for dressing, bathing, and transfers. The care plan and OT evaluation both specified daily OT sessions five times a week for four weeks. However, OT treatment encounter notes showed that while the prescribed frequency was met during the first three weeks, the resident only received four sessions in the fourth week, and just one session per week in the subsequent two weeks. The Director of Rehabilitation confirmed during interview and record review that the resident did not receive OT treatment at the frequency specified in the plan of care, and there was no documentation explaining the missed sessions. The facility's policy required staff occupational therapists to follow relevant physician orders and implement treatment plans in consultation with the resident's physician, but this was not adhered to in this case.