Failure to Provide Ordered PT/OT Evaluations and Rehabilitative Services
Penalty
Summary
The facility failed to provide or obtain specialized rehabilitative services as required for two residents, resulting in a year-long delay in the initiation of physical therapy (PT) and occupational therapy (OT) evaluations that were ordered by physicians. For one resident with diagnoses including dementia, stroke, aphasia, and hemiplegia, there was no evidence of a formal PT or OT evaluation or restorative nursing assistant (RNA) services after the initial order. The resident was entirely dependent on staff for activities of daily living (ADLs) and was observed to be non-verbal and positioned in bed with bent limbs. Care plans did not address the resident's stroke diagnosis or risk for ADL decline, and the Director of Rehabilitation acknowledged that the resident should have received a formal evaluation and RNA services to maintain functional status. Another resident with encephalopathy, multiple sclerosis, and a stage four pressure ulcer also did not receive the ordered PT and OT evaluations. The resident had severe joint mobility limitations and was dependent on staff for all ADLs. Despite a physician's order for therapy evaluations, only a Joint Mobility Assessment was performed, which the Director of Rehabilitation later stated was not a substitute for a full PT or OT evaluation. The resident confirmed not receiving therapy services, and medical records supported the absence of formal evaluations or RNA services. Facility policies required that residents with limitations in range of motion be referred to therapy for focused assessment and that specialized rehabilitative services be provided as indicated by comprehensive assessment and care plans. The failure to conduct the ordered evaluations and implement appropriate care planning for both residents was confirmed through interviews, record reviews, and direct observation.