Failure to Provide Ordered Physical Therapy Evaluation
Penalty
Summary
A deficiency occurred when a resident with a complex medical history, including type 2 diabetes mellitus, hypertensive heart disease with heart failure, congestive heart failure, atrial fibrillation, and a history of transient ischemic attack, did not receive a physical therapy (PT) evaluation as ordered by the physician. The resident was admitted on 11/11/2025, and an order for PT and occupational therapy (OT) evaluation and treatment was placed on 11/21/2025. While the resident received OT services as ordered, there was no documentation of a PT evaluation or screening being completed by 12/02/2025. The resident reported not having received PT services since admission, and facility records confirmed the absence of a PT evaluation. Interviews with facility staff revealed that the resident was evaluated by OT but not by PT, and that the facility required administrative approval to cover PT services for Medicaid residents. The Regional Director of Therapy was unaware of the PT evaluation order and only knew of the OT evaluation. Facility protocol requires all new admissions to be screened by therapy for potential skilled therapy services, including PT, OT, or speech therapy. Despite this protocol and the physician's order, the PT evaluation was not completed, resulting in a failure to provide specialized rehabilitative services as required.