Failure to Implement and Communicate Therapy Recommendations and Provide Adaptive Equipment
Penalty
Summary
The facility failed to ensure that therapy recommendations were effectively communicated to nursing staff and implemented in the care of multiple residents. For one long-term resident, a physical therapy discharge summary recommended the use of an ankle brace and a hemi walker as part of a functional maintenance program. However, there was no physician order or care plan documentation for the ankle brace, and nursing staff were unaware of its use, despite therapy staff confirming the recommendation. The resident reported that the ankle brace was kept in the therapy room rather than being available for use during ambulation. Another resident with a right-hand contracture was observed multiple times without a splint or palm guard in place, despite a provider's order for a palm guard to prevent further contracture. A previous therapy referral for splinting was not addressed, and occupational therapy only provided recommendations for self-feeding setup without addressing the contracture. Nursing staff confirmed the absence of the device during observation and only located it after being prompted. A third resident had a physician's order for foam utensil adaptors to be used at meals to promote independence, but the care plan did not include this intervention, and the adaptive device was not available during meal observation. The resident, their spouse, and therapy staff confirmed the device had not been available for a week, and the unit manager acknowledged the deficiency. These findings demonstrate a lack of effective processes to ensure therapy recommendations and adaptive equipment are consistently communicated, documented, and provided as ordered.