Delayed Therapy Assessment Following Resident Decline
Penalty
Summary
A deficiency was identified when a resident, previously independent in activities of daily living, experienced a decline in functional status following two recent hospitalizations for pneumonia and an appendectomy. Despite the resident and her family reporting increased difficulty with mobility and daily tasks, and the family independently purchasing a scooter to assist her, there was no evidence that therapy services had assessed or intervened in response to her decline. The resident stated she was not receiving therapy, and the family confirmed that the decision to purchase a scooter was made without input from therapy staff. Clinical record review showed that a rehabilitation referral was initiated due to the resident's change in condition, but the referral was not completed or acted upon for nine days. The therapy assessment was only performed after concerns were raised by the surveyor, revealing a significant decline from the resident's prior level of function. The Director of Nursing confirmed that the therapy evaluation was delayed, and the referral paperwork was not completed in a timely manner, resulting in a lack of appropriate assessment and intervention for the resident's change in condition.