Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
A deficiency occurred when a resident did not receive physician-ordered physical therapy (PT) and occupational therapy (OT) services for a total of seven days in June. The resident, who was cognitively intact and had significant mobility and self-care deficits, was admitted with diagnoses including atrial fibrillation, muscle weakness, unsteadiness, and a cognitive communication deficit. Orders were in place for both PT and OT to be provided multiple times per week, but therapy was not delivered from 06/16/25 through 06/20/25 and again from 06/23/25 through 06/24/25, as confirmed by therapy logs and progress notes. The lapse in therapy services was linked to confusion surrounding the appeal process after a Notice of Medicare Non-Coverage (NOMNC) was issued. The responsible party (RP) communicated that the appeal was won, but therapy was not resumed promptly due to an oversight by the Director of Rehabilitation (DOR), who admitted to forgetting to add the resident back to the therapy schedule. During this period, the resident remained in bed and did not receive the ordered therapy, which was corroborated by both the resident and the RP during interviews. Interviews with facility staff, including the DOR, Assistant Director of Nursing (ADON), Director of Nursing (DON), and interim Administrator, revealed a lack of awareness regarding the missed therapy sessions. The DOR acknowledged responsibility for ensuring therapy was provided as ordered and attributed the failure to an oversight. The ADON and DON were not aware of the missed sessions, and the DON stated there was no policy in place regarding therapy provision. The interim Administrator also confirmed that the DOR was responsible for ensuring therapy orders were followed.