Failure to Implement Recommended ADLs Restorative Program After OT Discharge
Penalty
Summary
The facility failed to implement a recommended restorative program for activities of daily living (ADLs) for a resident following discharge from occupational therapy (OT) services. The resident, who had diagnoses including orthopedic care, left femur fracture, high blood pressure, spinal stenosis, and dementia, was readmitted after a fall incident. Upon readmission, therapy evaluations were recommended, and both physical therapy (PT) and OT assessments were completed. The PT evaluation resulted in a restorative program for ambulation, which was implemented and documented as being followed daily. However, although the OT evaluation recommended a restorative program for ADLs such as personal hygiene, dressing, and grooming, this program was not implemented. Staff interviews confirmed that the resident never participated in an ADLs restorative program, and the Assistant Director of Nursing acknowledged that the evaluation for the ADLs program was not reviewed or acted upon after it was completed and locked by OT. This omission resulted in the resident not receiving the specialized rehabilitative services as required.