Failure to Re-Evaluate Resident for Rehab Services After Decline in ADLs
Penalty
Summary
The facility failed to obtain rehabilitation services for a resident who experienced a decline in activities of daily living (ADLs). According to facility policy, residents are to receive care and services to maintain or improve their ability to perform ADLs, and those identified as needing functional assessment should be evaluated for rehabilitation services. The resident in question, admitted with diagnoses including anxiety, dementia, and unsteadiness, had moderate cognitive impairment and required substantial to maximal assistance with ADLs. After being discharged from physical therapy, the resident's care documentation showed a further decline in ADL performance, with increased dependence noted in toileting, bathing, transfers, and mobility. Despite this documented decline, there was no evidence in the medical record or therapy notes that the resident was re-evaluated by therapy or screened for potential rehabilitation services following the change in condition. The Director of Rehab confirmed that no screen or evaluation was found after the resident's decline, although facility policy requires notification and assessment by the rehab department in such cases. This lack of follow-up and failure to initiate a therapy evaluation after a significant decline in ADLs constituted the deficiency identified by surveyors.