Delay in Occupational Therapy Evaluation Following Referral
Penalty
Summary
The facility failed to ensure a timely evaluation by occupational therapy (OT) services after a referral was made for a resident. Nursing staff made a referral for an OT evaluation due to the resident's onset of decreased strength, decreased endurance, and functional decline, as documented on the Interdisciplinary Rehabilitation Screening Form. However, there was no documentation of an OT evaluation being completed following the referral. The Director of Nursing confirmed that the referral was made, but the evaluation was not documented, and the Director of Therapy acknowledged that the referral was not processed in a timely manner. The Director of Therapy explained that the staff member responsible for OT evaluations was on medical leave at the time, but an alternative provider was available via telehealth and could have performed the evaluation when the referral was made. The facility's policy requires that therapy referrals be evaluated within 24-48 hours of receipt. The resident involved had a diagnosis of Alzheimer's Disease and a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment at the time of the deficiency.