Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
A resident with central spinal cord syndrome and a history of receiving physical, occupational, and speech therapy did not receive specialized rehabilitative services as ordered. The resident's care plan was updated to include passive range of motion (PROM) and instructions to follow physical therapy (PT) orders. During a care conference, the resident and family requested additional PT due to observed movement in the resident's lower extremities. A provider subsequently ordered a PT evaluation, but the evaluation was not completed after the order was written. Interviews with staff revealed that the PT order was not acted upon, with the LPN confirming that the order "fell through the cracks." The director of nursing stated that the expectation was for therapy to evaluate residents within 72 hours of a new order and to communicate the therapy plan to nursing staff within one week. Despite these expectations, the resident was not evaluated by PT after the new order, and the facility was unable to provide a policy for therapy services when requested.