Failure to Provide Ordered Rehabilitation Services Due to Staffing Shortages
Penalty
Summary
The facility failed to provide occupational and physical therapy services as ordered for three of four sampled residents who required specialized rehabilitative services. According to the facility's own policy, such services are to be provided under physician orders by qualified personnel and are considered part of the facility's scope of services. However, documentation and staff interviews confirmed that residents did not receive the therapy sessions as prescribed. One resident with chronic venous hypertension and ulcers was evaluated for physical therapy four to five times per week but did not receive any sessions beyond an initial refusal, with no further attempts documented. Another resident with hemiplegia following a stroke was evaluated and ordered to receive physical therapy twice weekly but only received one session, with no explanation for the lack of further therapy. A third resident with diffuse large B-cell lymphoma and diabetes, who required assistance with mobility and was at risk for falls, was ordered to receive both physical and occupational therapy three to five times per week but only received two sessions of each per week, less than what was ordered. Staff interviews revealed that the primary reason for the missed therapy sessions was insufficient therapy staffing, which prevented the facility from meeting the frequency of therapy sessions indicated in the residents' evaluations and physician orders. The Director of Rehabilitation, who was responsible for scheduling, worked offsite and confirmed the lack of adequate staff to provide the required services. The facility administrator acknowledged the issue, stating that the census of residents needing therapy exceeded the available therapy staff.