Failure to Follow Physician's Order for Therapy Screening
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for therapy screening for a resident with multiple sclerosis who had no movement in her lower extremities and limited movement in her upper extremities. After being transferred to the hospital for flu-like symptoms and increased upper extremity weakness, the resident was evaluated by a neurologist who recommended rehabilitation directed at her upper extremities upon return to the facility. A physician's order for PT, OT, and ST evaluation was entered and later discontinued, but there was no evidence that the therapy department received or acted upon the order during the relevant period. Interviews revealed that the therapy department was not made aware of the order for therapy screening or the hospital's recommendation for therapy. The Director of Therapy Services stated that therapy orders do not go directly to the therapy department and require nursing staff to forward them. As a result, the resident did not receive the recommended therapy screening or services following her hospital discharge, and the therapy department only became aware of the need for screening at a later scheduled quarterly review.