Failure to Implement Physician Orders for Occupational Therapy and Cognitive Testing
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician's order for occupational therapy evaluation, treatment, and cognitive testing was implemented according to professional standards for one resident. The resident had diagnoses including mild cognitive impairment, chronic kidney disease, and a history of breast cancer, and was noted to have daily wandering behaviors and moderate cognitive impairment. The physician assistant issued an order for occupational therapy and cognitive testing, with instructions for therapy to provide the results to the provider. Despite the order being transcribed and placed in the therapy box by the registered nurse case manager, it was not communicated to the therapy director or followed up on by nursing staff. Interviews revealed that the occupational therapy department had not received the order, and the director of nursing confirmed that the order was not communicated as required. The physician assistant stated that her expectation was for orders to be processed promptly and communicated to the appropriate staff. A policy for following physician orders was requested but not provided.