Failure to Follow Physician Orders for Therapy Evaluation
Penalty
Summary
A deficiency occurred when the facility failed to follow physician orders for a resident who required evaluation and possible treatment by physical and occupational therapy. The resident had a history of diverticulosis, syncope, congestive heart failure, chronic kidney disease, and alcohol abuse, and was noted to have moderate cognitive impairment with a BIMS score of 8. The resident required mobility devices and partial to moderate assistance with activities of daily living. Despite a physician order dated 4/9/25 for PT/OT evaluation and treatment, there was no evidence that the therapy department was notified or that the evaluation was completed. Interviews with the DON, occupational therapist, and physical therapy assistant revealed that the therapy department relies on nursing staff to communicate therapy orders, typically through verbal communication or morning meetings. In this case, the therapy staff were not informed of the order, and as a result, the resident was not evaluated by therapy. Review of facility policies and job descriptions confirmed that both nursing and therapy staff are responsible for communication and implementation of therapy orders, but the process failed, resulting in the resident not receiving the ordered therapy evaluation.