Failure to Provide Ordered Therapy Services Upon Admission
Penalty
Summary
A deficiency occurred when a resident admitted with diagnoses including Parkinson's disease, a healing left ankle fracture, weakness, and low back pain did not receive ordered physical and occupational therapy services upon admission. The resident's Minimum Data Set (MDS) indicated intact cognition and dependence on staff for mobility and transfers, with care plan interventions specifying the use of a walker, wheelchair, and assistance from staff. Physician orders and the inpatient summary documented the need for both physical and occupational therapy evaluations and treatments, as well as specific mobility aids and weight-bearing instructions. Despite these orders, the clinical record lacked documentation that the resident received the required therapy services on the day of admission. Both the resident and their family confirmed that no therapies were provided at that time. Facility leadership, including the DON and Administrator, acknowledged the absence of therapy documentation and confirmed that the expectation is for physician orders to be followed and therapies to be provided as ordered.