Failure to Complete Therapy Evaluation After Hospital Readmission
Penalty
Summary
The facility failed to ensure that a therapy evaluation was completed for a resident upon readmission following an inpatient hospital stay. The resident, who had diagnoses including muscle weakness and required assistance with personal care, was discharged from the facility, hospitalized, and then readmitted. Upon return, the resident reported feeling weaker and more easily fatigued than before her hospitalization. Despite hospital discharge documentation and orders explicitly stating the need for occupational and physical therapy evaluation and treatment at the receiving facility, no therapy evaluation was conducted after her readmission. Interviews with facility staff revealed that the therapy manager and clinical care coordinator did not consider hospitalization alone as a reason to screen for therapy services, and believed that if a resident returned at their baseline, no therapy referral was necessary. However, hospital records indicated the resident required further skilled occupational therapy, and discharge instructions included orders for therapy evaluation and treatment at the facility. The interim director of nursing confirmed that the resident was not evaluated by therapy upon readmission, contrary to expectations.