Failure to Provide Therapy Services as Ordered and Document Reasons for Missed Sessions
Penalty
Summary
The facility failed to provide physical therapy (PT) services in accordance with physician orders for one resident who had a history of hemiplegia and hemiparesis following a cerebral infarction, as well as muscle wasting and atrophy. The resident was admitted with significant deficits in activities of daily living (ADLs) and had orders for PT evaluation and treatment five times a week for 30 days, with subsequent recertifications to continue therapy at the same frequency. Documentation showed that during one week, the resident received PT only three times instead of the five times ordered, with no explanation documented for the missed sessions. Interviews with the Director of Rehabilitation and the Physical Therapy Assistant confirmed that the resident was scheduled for therapy on the missed days, but there was no documentation as to why therapy was not provided. The facility's policy required care and services to be provided and documented in accordance with physician orders and professional standards. The lack of documentation for the missed therapy sessions and absence of communication regarding the reasons for not providing therapy constituted a failure to follow physician orders and facility policy.