Failure to Refer Resident for PT/OT After ADL Decline
Penalty
Summary
A deficiency occurred when the facility failed to refer a resident with Alzheimer's disease, functional quadriplegia, and weakness to physical therapy (PT) and occupational therapy (OT) after a documented decline in activities of daily living (ADLs). The resident's quarterly Minimum Data Set (MDS) assessment showed a progression from requiring setup or clean-up assistance with eating and partial to moderate assistance with personal hygiene, to being fully dependent on staff for these activities. The care plan reflected this increased dependency, but there were no physician orders for PT or OT to address the decline during the relevant period. Interviews with facility staff, including the MDS Coordinator and the Director of Rehabilitation, confirmed that a referral to PT/OT should have been made following the identified decline in ADLs. The MDS Coordinator acknowledged responsibility for initiating such referrals and could not provide a reason for the omission. The Director of Rehabilitation stated that the last PT/OT assessment for the resident was several months prior and agreed that a new referral was warranted based on the recent decline. Facility policy also indicated that residents with significant changes in functional condition should be evaluated for rehabilitation services.