Failure to Provide Required Occupational Therapy Evaluation and Interventions
Penalty
Summary
A deficiency was identified when a resident with hemiplegia affecting the left non-dominant side and a left-hand contracture did not receive an Occupational Therapy (OT) evaluation as required. The resident was previously seen by OT from April to August of the prior year for activities of daily living and fall risk, but there was no documentation of any further OT screening or evaluation after that period. The Minimum Data Set (MDS) quarterly assessment indicated a limitation in the range of motion of the upper and lower extremity on one side, and the care plan included interventions such as the use of supportive devices and splints for the left hand contracture. Despite these documented needs, there was no evidence in the medical record or Treatment Administration Record (TAR) of ongoing treatment or intervention for the contracture after August of the previous year. Observations confirmed that the resident was not using a splint or any supportive device on the affected hand, and the resident reported being unable to completely open the hand. The lack of follow-up OT evaluation and absence of prescribed interventions contributed to the facility's failure to provide specialized rehabilitative services as required.