Failure to Initiate and Transcribe Physical Therapy Orders
Penalty
Summary
Facility staff failed to ensure that services met professional standards of quality when a physical therapy order for one cognitively intact resident with paraplegia and generalized muscle weakness was not initiated or transcribed into the medical record. The resident’s care plan identified goals related to paraplegia and general weakness, including remaining as independent as possible and receiving restorative care for passive/active range of motion as ordered. Outpatient discharge records contained an order for physical therapy at least one hour per day, five days per week, for core and bilateral lower extremity strength, range of motion, transfers, and mobility. However, review of the physician order summary showed no corresponding order for restorative care or physical therapy. The resident reported having previously received physical therapy but stated that it had not been provided for about a month and a half, despite the expectation of restorative therapy and a desire for additional exercise to maintain strength and independence. An LPN stated that the process for activating outside clinic orders involved faxing them to the physician for approval and then transcribing approved orders, and believed the physical therapy order had been sent but did not recall receiving a response. The facility director stated that outside orders should be communicated to the physician and, once approved verbally or in writing, transcribed by nursing staff, but acknowledged that the physical therapy order appeared not to have been transcribed. The administrator stated that the physician reviews new orders and that nursing staff and the director are responsible for follow-up on all orders. The physician reported having tried to obtain physical therapy for the resident for a long time, did not recall receiving a faxed order for this therapy, and stated that if it had been received, it would have been approved, indicating that the ordered therapy was never implemented.
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