Failure to Initiate Physician-Ordered Therapy Services Upon Admission
Penalty
Summary
The facility failed to provide needed services in accordance with professional standards by not initiating physician-ordered physical therapy (PT) and occupational therapy (OT) for a resident following admission. The resident, who had a right below-the-knee amputation and severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 3, was admitted with physician orders for PT and OT on 8/4/25. However, these therapy services were not started until nearly a month later, despite the orders being present in the electronic health record. Staff interviews confirmed that the therapy department did not receive the order until 8/27/25, and therapy services began in early September. The Director of Nursing acknowledged that the initial orders from 8/4/25 were missed and not followed, resulting in a delay in therapy services. Facility policy required timely and accurate implementation of physician orders, including therapy, upon admission, but this was not adhered to in this case.