Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered by the physician for one resident who required assistance with position and mobility. The resident, who had multiple medically complex conditions, was dependent on staff for all mobility and required substantial to maximal assistance with daily activities such as dressing, transfers, and wheelchair mobility. Physician orders specified occupational therapy (OT) five times per week and physical therapy (PT) three times per week. However, therapy calendars and documentation showed that the resident did not consistently receive the ordered frequency of therapy sessions, with some weeks showing reduced numbers of sessions for both OT and PT. During interviews and observations, the resident reported missing therapy sessions, sometimes due to dialysis appointments, but also noted that therapists occasionally did not show up without explanation. The Therapy Director confirmed that missed therapy sessions should have been documented with reasons for absence or refusal, but such documentation was not available. Staff were unable to provide records of refusals or explanations for the missed sessions, indicating a lack of adherence to the prescribed therapy regimen.