Failure to Implement Physician Order for PT/OT Evaluation and Wheelchair
Penalty
Summary
The facility failed to ensure that a physician's order for physical therapy (PT) and occupational therapy (OT) evaluation, as well as a wheelchair, was carried out for a resident with significant mobility and self-care deficits. The resident, who had diagnoses including dementia, Alzheimer's disease, diabetes mellitus, and muscle weakness, was initially able to ambulate with a walker and perform some activities of daily living (ADLs) with moderate assistance. Over several months, the resident experienced a decline in mobility, becoming increasingly bedbound and eventually requiring a wheelchair and mechanical lift for transfers. Despite a physician's order dated 10/23/2024 for PT/OT evaluation and a wheelchair, there was no documented evidence that the order was communicated to or carried out by the therapy department. Interviews with therapy staff revealed they were unaware of the order and had not reassessed the resident after the initial therapy discharge. Nursing staff also confirmed that the order was not implemented or communicated, and the resident's decline in function was not addressed with appropriate therapy referrals or interventions. The facility's own policies and job descriptions required that physician orders be carried out promptly and that referrals to other departments, such as therapy, be completed as needed. However, the failure to implement the physician's order resulted in delayed treatment and services for the resident, as confirmed by multiple staff interviews and record reviews.