F0826

D

Failure to Provide Ordered Therapy Evaluation at Admission and Post-Fall

Kingsland, Texas Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that specialized rehabilitative services were provided by qualified personnel as ordered by a physician and as outlined in the resident’s care plan. A male resident with multiple complex diagnoses, including Type 1 diabetes with kidney complications, sepsis, nontraumatic subarachnoid hemorrhage, hemiplegia and hemiparesis following cerebral infarction, acute bronchiolitis due to RSV, and orthostatic hypotension was admitted with a physician order for PT, OT, and ST to evaluate and treat as indicated. The admission MDS showed moderate cognitive impairment with a BIMS score of 9 and documented that the resident required setup or clean-up assistance for some functional activities. Despite the standing physician order for therapy evaluation and treatment, the therapy department did not screen or evaluate the resident upon admission.

The resident’s care plan, initiated on the date of admission, identified an ADL self-care performance deficit related to confusion and a moderate risk for falls, and it documented a fall on a later date with an intervention specifying that PT was to evaluate and treat as needed after a fall. The resident experienced a fall next to the kitchen door, and nursing completed a Nursing to Therapy Screen Request in the electronic record, indicating a post-fall reason and requesting PT due to recent physical function changes. However, the Director of Rehabilitation (DOR) did not act on this request and did not perform a screening or evaluation following the fall, despite the care plan intervention and the facility’s process that a fall triggers a therapy evaluation request.

Interviews revealed that the DOR chose not to screen or evaluate the resident upon admission because she believed there was no payer authorization from the hospital and stated that the therapy department usually did not treat residents without funding unless directed by the Administrator. The Business Office Manager (BOM) stated that all new admissions were to be screened or evaluated by therapy unless admitted only for nursing services and that treatment decisions were based on payer source, but also indicated that this resident was to be handled through an administrative authorization process. The Administrator and Regional Nurse both stated that all new admissions should be screened by therapy regardless of payment source and that PT should evaluate after every fall per facility standard, with payer source not preventing evaluation. The DOR later acknowledged that there was a communication in the electronic medical record regarding the resident’s fall that she did not see because she had not been checking the dashboard daily. Facility policies on fall risk assessment, falls clinical protocol, and resident screening guidelines required interdisciplinary assessment of fall risk factors and therapy screening on all new admissions and upon referral, but these processes were not followed for this resident at admission or after the fall.

The facility’s fall risk assessment policy required nursing staff, the attending physician, therapy staff, and others to identify and document resident risk factors for falls and to establish a resident-centered fall prevention plan based on assessment data, including evaluation of ambulation, mobility, gait, balance, ADL capabilities, and cognition. The falls clinical protocol required assessment and recognition of fall risk, documentation of recent falls, and evaluation of musculoskeletal function and neurological status after a fall, with staff attempting to define possible causes within 24 hours. The resident screening guidelines policy required that screenings be completed by licensed therapy staff on all new admissions or upon referral to help identify functional loss and the need for rehabilitation services. Despite these written policies, the resident did not receive the ordered therapy evaluation at admission, and the post-fall therapy evaluation and treatment intervention in the care plan was not implemented after the documented fall and therapy referral.

The Administrator stated that the therapy department should have assessed the resident when there was a request in the electronic system and that payer source was not a factor in determining the need for assessment. The Regional Nurse stated that once there is a fall, it triggers a form to be sent to therapy to evaluate the resident and that therapy should screen every resident, with further treatment decisions made after evaluation. The DOR stated she was new to the position, was still learning the process, and had only become aware of the nursing communication regarding the fall after the surveyor’s inquiry. These interviews and record reviews collectively showed that the facility failed to ensure that therapy services evaluated and treated a function impaired by illness or injury and failed to increase the resident’s functioning as ordered, by not conducting the required therapy evaluations at admission and after the fall, contrary to physician orders, the resident’s care plan, and facility policies.