Failure to Provide Ordered Rehabilitative Services Due to Staffing Shortages
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered by physicians and outlined in the comprehensive care plans for two residents. One resident with a history of cerebral infarction and muscle weakness had physician orders and a care plan for daily physical therapy six times per week for six weeks. However, therapy session documentation revealed multiple missed visits due to staffing shortages and scheduling conflicts, such as the resident eating during therapy times. Another resident, who had experienced a recent cerebrovascular accident and was at risk for nutrition issues, had orders for daily occupational therapy and speech therapy. This resident also missed several therapy sessions due to staffing shortages. Interviews with facility staff confirmed that therapy visits were missed because of ongoing staffing shortages, with reliance on as-needed therapists who often arrived during residents' mealtimes, further contributing to missed sessions. The facility's policy required timely provision of therapy services as ordered, but this was not consistently followed, resulting in the failure to deliver prescribed rehabilitative care to the affected residents.