Failure to Provide Ordered Physical Therapy During Rehab Service Transition
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered rehabilitative services, specifically PT, to a resident in accordance with physician orders and the care plan. Resident 1 was admitted with acute and chronic respiratory failure, recent pulmonary emboli, muscle weakness, and a need for assistance with personal care. The MDS dated 1/6/26 indicated no memory impairment. Physician orders dated 12/30/25 directed skilled PT services five times per week for four weeks, including therapeutic exercises, therapeutic activities, neuro re-education, gait training, and patient/caregiver training. The resident’s care plan, initiated the same day, identified generalized weakness, impaired functional mobility, balance deficits, and increased need for caregiver assistance, with interventions that included the same ordered PT services. During interviews and record review, surveyors found that these PT services were not provided. The Administrator reported that the facility ended its contract with the outside rehab provider at the start of the year and was transitioning to in-house rehab staff, with only one OT hired from the former contractor and a PTA scheduled to start later. The OT confirmed that since the contract ended, no PT, OT, or SLT staff from the outside provider had come to the facility and that, at the time of the survey, the facility could only provide OT services. The OT stated the facility did not have a PT, so the resident did not receive the ordered PT. The DON acknowledged the PT order in the electronic record and stated most of the resident’s PT was due during the transition period. The RNA staff reported the resident was not on the restorative list and had not been discharged from PT to restorative services. The resident reported needing PT to be able to walk, stated she had not had any PT appointments, and recalled only possibly seeing a therapist once with a promise that therapy would start soon. The facility’s policy on scheduling therapy services required that therapy be scheduled in accordance with the resident’s treatment plan, which did not occur for PT in this case.
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