Failure to Provide Ordered Physical Therapy and Document Missed Sessions
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including end stage renal disease, encephalopathy, respiratory failure, wounds, and legal blindness, did not receive physical therapy services as ordered by the physician. The resident was supposed to receive physical therapy four times a week for four weeks, as documented in the care plan and physician's orders. However, during the week in question, the resident only received three physical therapy sessions instead of the prescribed four. There was no documentation in the clinical record explaining the missed session or the reason for the deviation from the physician's order. Interviews and record reviews confirmed that facility staff did not document the missed physical therapy visit or provide a reason for the absence, despite facility policy requiring such documentation. The lack of adherence to the prescribed therapy schedule and the absence of required documentation were confirmed by the Regional Rehab Resource during a review of the resident's clinical record. Facility policies and best practices reviewed also indicated that all missed or refused treatments should be documented, which was not done in this case.