Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required by the plan of care for a resident who had been admitted with a diagnosis of cerebral vascular accident resulting in left hemiparesis. The resident's care plan included orders for both Occupational Therapy (OT) and Physical Therapy (PT), with specified goals and a frequency of six times per week for eight weeks. Documentation showed that the resident was evaluated by both PT and OT, but there was no evidence that the resident received any therapy sessions as ordered during their short stay. Notes indicated that therapy was withheld or that the resident did not participate, and the resident was ultimately discharged to the hospital after only a few days in the facility. Interviews with facility staff, including the Rehab Director, confirmed that while evaluations were completed, there was no documentation of actual therapy sessions being provided. The Rehab Director was unable to locate any additional therapy notes and stated that the resident did not receive therapy due to the brief duration of their stay. Family members also reported that the resident did not receive therapy during their time at the facility.