Delayed Therapy Evaluations and Treatments for New Admissions
Penalty
Summary
The facility failed to provide physician-ordered specialized rehabilitative services, specifically PT and OT, in a timely manner for two residents. For one resident admitted with respiratory failure with hypoxia, metabolic encephalopathy, and anxiety, transfer orders dated 01/02/2026 included PT and OT evaluation and treatment. However, the medical record showed that the initial PT and OT evaluations and treatment plan were not completed until 01/06/2026, five days after admission. A comprehensive assessment dated 01/05/2026 documented that this resident required set-up to partial assistance for ADLs and supervision/touch assistance for transfers, with intact cognition. During interview, the resident reported they were not getting much therapy and felt they would be better off at home doing their own therapy. Another resident was admitted following hip replacement surgery with additional diagnoses including long-term use of anticoagulants, anxiety, and depression. The comprehensive assessment showed this resident required substantial assistance for showers, lower body dressing, and transfers, and had moderately impaired cognition. The record showed the initial PT evaluation and treatment plan occurred four days after admission and the OT evaluation and treatment plan occurred five days after admission. The resident was discharged home after receiving only one PT treatment and one OT treatment. In interview, the resident stated they wished therapy had started on the day of admission but were told therapy could not be provided because the Director of Rehabilitation was not present that day. The Director of Rehabilitation reported the facility was short PT staff, with full-time PT staff working Monday through Thursday, resulting in residents admitted on Friday waiting until Monday for therapy evaluations, and stated their understanding that professional standards called for therapy evaluations within three days of admission. The Administrator similarly stated their understanding that therapy evaluations should be completed within the first three days of admission.
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