Failure to Initiate Timely Occupational Therapy Referral for Contracture Management
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and care in accordance with professional standards for a resident with upper extremity contractures. The resident, who had a history of stroke, traumatic brain injury, and dementia, was observed to have significant contractures in both upper extremities. The resident was unable to communicate effectively and was noted to have impaired range of motion, with both hands closed and arms held closely to the chest. The care plan and multiple assessments documented the presence of contractures and the need for monitoring changes in functional abilities. On a specific date, the nurse practitioner (NP) documented a recommendation for an occupational therapy (OT) referral to address the resident's worsening contractures. However, there was no evidence that an order for OT services was placed in the medical record following this recommendation. Interviews with facility staff, including the Director of Rehab (DOR), OT, and DON, revealed that the referral process was not followed, and the OT was not made aware of the NP's recommendation until the issue was brought up by a surveyor. The facility's policy required that therapy referrals be evaluated within 48 hours, but the resident was not evaluated by OT until 49 days after the NP's recommendation. Documentation failed to show that a paper referral form was completed or that any contraindications for therapy were documented. Staff interviews indicated a lack of clarity and communication regarding the referral process, with the NP assuming therapy had begun and the DOR and OT unaware of the referral. As a result, the resident did not receive timely OT evaluation and intervention for contracture management as recommended by the NP and required by facility policy.