Failure to Implement Timely PT/OT Orders for Resident with Declining Mobility
Penalty
Summary
A deficiency occurred when the facility failed to implement a physician's order for physical therapy (PT) and occupational therapy (OT) services in a timely manner for a resident with a history of dementia, Alzheimer's disease, diabetes mellitus, and muscle weakness. The resident was initially admitted with the ability to walk independently or with a walker and received PT and OT services upon admission. These therapy services were discontinued after the resident achieved maximum potential, and the resident was discharged from therapy with an order for the Restorative Nursing Assistance (RNA) program. However, as the resident's mobility declined over several months, no further referrals for PT or OT were made, and the RNA program was not re-initiated for PT. Despite a significant decline in the resident's mobility and increased dependency in activities of daily living (ADLs), there was no documented assessment or intervention by nursing staff. The resident's responsible party reported noticing the decline and requested more therapy, but therapy services were not resumed. Nursing progress notes and physician orders did not reflect any assessment or action regarding the resident's mobility decline, and there was no evidence that the physician's order for a PT/OT evaluation and wheelchair was communicated to or carried out by the therapy department. Multiple staff interviews confirmed that the order for PT/OT evaluation, written and signed by the physician, was overlooked and not implemented. The PT and OT staff were unaware of the order and the resident's current functional status until the issue was brought to their attention during the survey. The facility's policies and job descriptions required that physician orders be carried out promptly and that referrals to therapy be made as needed, but these procedures were not followed, resulting in delayed care and treatment for the resident.