Failure to Provide Ordered Physical Therapy and Restorative Nursing Services
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered rehabilitative services within a reasonable timeframe for one resident. The resident reported not having been in therapy and that no one had seen her about therapy, despite her desire to participate. Record review showed she had multiple diagnoses, including non-active primary progressive multiple sclerosis, contractures of muscles in the right lower leg, left leg, and right upper arm, and secondary progressive multiple sclerosis unspecified. A prior PT evaluation documented an order for PT five times per week for four weeks, and a later PT treatment note showed that only one PT session had occurred. Further record review revealed an active physician’s order for PT three times per week for 30 days for skilled PT services, including ROM, safe transfers, and bed mobility, as well as an order for a Restorative Nursing Program three times per week for passive ROM to the bilateral lower extremities and active ROM to the bilateral upper extremities. The Activities Director, who oversaw the Restorative Nursing Program, stated she had not received an order from the Director of Therapy to initiate the program for this resident and confirmed that, despite the active RNP order, the resident was not receiving any restorative services. This lack of implementation of both PT and restorative nursing orders led to the identified deficiency.
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