Failure to Implement Physical Therapy Maintenance Program for Resident
Penalty
Summary
The facility failed to provide necessary services recommended by physical therapy to maintain or improve a resident's ability to perform activities of daily living. After the resident's physical therapy treatment ended, a functional maintenance program was ordered by physical therapy, but the facility did not initiate the program. The resident's care plan did not include the prescribed exercises, and staff were unaware of the recommendations. The physical therapy assistant stated that a maintenance program was provided to nursing staff, but the form could not be located, and the nurse manager was not aware of any PT recommendations for the resident. The form was later found in a pile waiting to be scanned, indicating a breakdown in communication and implementation of the therapy plan. The resident involved was cognitively intact, dependent on staff for several activities of daily living, and had diagnoses including dementia, renal insufficiency, stroke, and seizure disorder. She expressed concern about her ability to discharge to a facility closer to home, as her discharge goal required her to stand and not use a bariatric mechanical lift. The lack of initiation of the functional maintenance program delayed her progress toward this goal. The facility did not have a designated restorative nurse, and the recommended exercises were not incorporated into the resident's care plan as required.