Rehabilitative Services Provided Without Physician Order
Penalty
Summary
The facility failed to ensure that specialized rehabilitative services were provided in accordance with federal regulations for one of two sampled residents. A resident who was readmitted with acute pulmonary edema and muscle weakness received both physical therapy (PT) and occupational therapy (OT) services for 25 days without a physician's order. Observations confirmed that the resident participated in PT and OT sessions, including sitting to standing transfers and arm exercises, under the guidance of therapy assistants. A review of the resident's clinical records revealed no documented physician's order for PT or OT treatment, nor any evidence that a physician had been notified about these services. During interviews, the Director of Rehab confirmed the ongoing therapy services, and the Director of Nurses stated unawareness of the regulatory requirement for a physician's order for such services. The facility did not have a formal policy or procedure to ensure physician oversight for rehabilitative treatments.