Failure to Provide Timely Physical Therapy Evaluation and Treatment
Penalty
Summary
The facility failed to provide a Physical Therapy (PT) evaluation and treatment as ordered by a physician for a resident with significant mobility and functional limitations. The resident, who had diagnoses including hemiplegia, hemiparesis, aphasia, and joint stiffness following cerebrovascular disease, was admitted and had a physician's order for PT and Occupational Therapy (OT) evaluation and treatment. Review of the resident's records showed that the PT evaluation was not completed, despite the order being present and the facility's policy requiring evaluations to be completed within 72 hours of the order. The Rehab Director confirmed that she was unaware of the order and that the nursing staff typically informs therapy of such orders, but this communication did not occur in this case. Observations of the resident revealed significant physical limitations, including a bent left elbow, fisted left hand, and limited movement in the right leg, consistent with the documented diagnoses and assessment findings. Interviews with facility staff, including the Rehab Director and DON, confirmed that the PT evaluation was missed and should have been completed as ordered. The facility's policy also required timely completion of such evaluations for residents referred by a physician, but this was not followed, resulting in a delay in the provision of necessary rehabilitative services.