Failure to Provide Ordered PT Services Due to Staffing Shortages
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services according to a resident’s established treatment plan. The facility’s policy on scheduling therapy services states that therapy is to be scheduled in accordance with the resident’s treatment plan. One cognitively intact resident, identified as Resident 15, was admitted in October 2025 and had a physician’s order dated 12/04/2025 for PT/OT to evaluate and treat, with partial weight bearing as tolerated. A PT Evaluation and Plan of Treatment dated 12/11/2025 specified a frequency of two times per week, with a certification period from 12/11/2025 through 02/23/2026. During an interview on 01/06/2026, the resident reported that the last time they received PT was two weeks prior. Record review of PT notes for Resident 15 showed no documentation of PT services provided between 12/19/2025 and 01/05/2026, an 18‑day gap, despite the ordered frequency. The PT (Staff R) stated that residents are to be seen according to the plan of treatment and that refusals should be documented with missed visit notes, but could not find any documentation explaining why Resident 15 did not receive PT during that period and referred the surveyor to the Director of Rehab. The Director of Rehab (Staff Q) stated that the resident did not receive PT services for two weeks due to staffing shortages and that they were not able to schedule the resident, and confirmed that absent staffing issues, the expectation was PT twice weekly. The Administrator (Staff A) stated they expected residents to receive therapy services per their treatment plan and confirmed that this expectation applied to Resident 15’s ordered twice‑weekly therapy.
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