Failure to Provide Required Rehabilitative Therapy Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically physical and occupational therapy, as required by the comprehensive care plan for one resident. The resident, a 39-year-old female with diagnoses including acute myocardial infarction and age-related physical debility, was documented as having significant upper and lower extremity impairments and required assistance for all self-care activities. Despite the PASARR Comprehensive Service Plan and PT evaluation indicating a need for daily physical therapy and occupational therapy, there was no evidence in the clinical record that these services were provided as ordered. The resident's care plan also noted the need for assistance with ADLs and risk for falls, with interventions including rehab therapy screening, but no documentation supported that therapy services were delivered. Record reviews showed the absence of active therapy orders and a lack of therapy minutes received, despite the resident's documented needs. Interviews with facility staff confirmed that therapy services should have been arranged, and that delays in therapy approval would typically result in enrollment in restorative care, which also was not documented. The facility was unable to provide therapy service policies when requested by surveyors, and the resident was unaware of the therapy services she was supposed to receive.