Failure to Provide Ordered Physical and Occupational Therapy
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically physical therapy (PT) and occupational therapy (OT), as ordered for one resident with a right lower extremity tibia fracture status post-surgical repair. Physician's orders required PT five times per week for multiple consecutive weeks and OT five times per week for several weeks. However, record review showed that for eight out of fourteen weeks, the resident did not receive PT at the ordered frequency, with some weeks having as few as two or three visits. Similarly, for three out of six weeks, the resident did not receive OT at the ordered frequency, with one week having only one visit and another week with no visits at all. Interviews with the resident's representative and the Director of Rehab confirmed that the resident did not receive the prescribed therapy sessions. The Director of Rehab acknowledged that therapy should have been provided according to physician's orders and that documentation, such as encounter notes or missed visit notes, was lacking for the missed sessions. There was no additional evidence in the medical record to account for the missed therapy visits.