Failure to Provide Ordered Physical Therapy Evaluation for Resident with Frequent Falls
Penalty
Summary
A deficiency occurred when the facility failed to provide therapy services as ordered for a resident with a history of frequent falls and a diagnosis of dementia. The resident had multiple falls in recent months, with eight falls documented in one month, and was known to be impulsive and prone to self-transferring. A physician's order was written for a physical therapy (PT) evaluation due to these frequent falls. However, the PT evaluation was not completed as ordered. Staff interviews revealed that the therapy manager determined PT was not appropriate because the resident had recently completed therapy, but this decision was not discussed with the resident's provider. Further review showed that the interdisciplinary team assumed the provider was informed of the decision to not proceed with the PT evaluation, but there was no evidence of direct communication with the provider regarding the appropriateness of the order. The failure to follow the physician's order for a PT evaluation left the resident without the specialized rehabilitative services that had been deemed necessary to address their risk for falls.