Failure to Provide Ordered Rehabilitative Services Due to Communication Breakdown
Penalty
Summary
A resident was admitted for orthopedic aftercare following a right fibula fracture, with additional diagnoses including severe osteoporosis, depression, chronic pain, muscle weakness, and difficulty walking. Upon admission, orders were written for both physical therapy (PT) and occupational therapy (OT) evaluations and treatments, with plans specifying services five times a week for several weeks. The resident was cognitively intact and expressed a desire to participate in therapy to regain strength and mobility, specifically aiming to reduce fall risk and improve ability to use a bedside commode. Despite having insurance coverage for the entire stay, the resident experienced a discontinuation of both PT and OT services after March 20, even though the treatment plans and insurance authorizations extended beyond that date. The clinical record did not reflect a physician order to discharge rehabilitative services, nor did the nursing care plan document the resident's goals for specialized rehab services. The resident reported not receiving therapy for approximately two weeks prior to discharge and was unclear about the reason, despite inquiring with staff. Interviews with facility staff confirmed that there was a miscommunication regarding the resident's coverage and discharge status, resulting in the resident not being re-evaluated or transitioned to restorative or continued rehabilitative services during the gap period. The resident expressed frustration and discouragement about not receiving therapy, feeling weaker, and not achieving her rehabilitation goals. She was not included in care plan meetings or discussions about her therapy, and staff interviews confirmed that the extension of her stay and continued eligibility for services were not effectively communicated to the rehabilitation department. Facility policies required individualized, person-centered care planning and the provision of specialized rehabilitative services as assessed, but these were not followed in this case.