Failure to Provide Physician-Ordered Therapy Services
Penalty
Summary
The facility failed to ensure that physician-ordered occupational therapy (OT) and physical therapy (PT) services were provided to two residents who required these specialized rehabilitative services. For one resident with multiple sclerosis, neuralgia, and depression, the admission assessment indicated a need for PT, OT, and speech therapy (ST), and transfer orders specified OT three times a week for four weeks and PT three times a week for up to 45 days. However, there were no therapy notes or documentation showing that OT or PT services were provided, and the resident reported not receiving any therapy during their stay. Staff interviews revealed confusion regarding therapy orders, with staff citing insurance coverage issues and a lack of documentation or evaluation by therapy staff. Another resident with a history of repeated falls and peripheral neuropathy was admitted with orders for PT and OT evaluation and treatment. The resident repeatedly requested therapy services and assistive devices to aid in mobility and independence, but was told by staff that a provider referral was needed and that long-term residents did not receive specialized therapy services. Medical records showed that therapy orders were discontinued shortly after admission, and the resident was instead placed on a restorative nursing program focused on upper extremity exercises, with no therapy provided for lower body mobility. Staff interviews indicated that therapy staff shortages and miscommunication contributed to the lack of therapy services, and there was a lack of awareness among staff regarding the resident's developing contracture and therapy needs. Documentation review and staff interviews confirmed that required therapy evaluations and treatments were not completed as ordered for both residents. Orders were either not entered, discontinued without follow-up, or not acted upon due to staff assumptions, insurance misunderstandings, or staffing shortages. The interdisciplinary team did not ensure that therapy needs were addressed, and there was no evidence that the residents received the specialized rehabilitative services necessary to maintain or improve their functional abilities.