F0658

D

Failure to Implement Physician-Ordered Physical Therapy Services

Helena, Montana Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that physician-ordered physical therapy services were implemented for one resident in accordance with professional standards of quality. Admission orders dated 12/23/25 included a physician’s order for physical therapy to evaluate and treat, and these admission orders were signed off by a nurse (NF2) on 1/1/26. However, review of the resident’s admission MDS with an ARD of 12/29/25 showed no therapy services documented in Section O0390, and a Census Details Report dated 3/23/26 confirmed the resident was never enrolled in therapy services at any time during the stay. The resident was later transferred to an assisted living facility on 2/10/26, per the request of NF1.

Interviews with staff revealed that the facility’s process for initiating therapy orders was not followed or failed at some point. Staff member D explained that when therapy orders are included in admission orders, the admitting nurse is responsible for forwarding a copy to the therapy department so that the physical therapist can complete the initial assessment, and stated that the resident’s initial therapy order may have been missed or not forwarded, leaving therapy staff unaware of the order. Staff member H stated that when a new therapy order is received, a PT evaluation is typically completed within a couple of days and treatments are then carried out by PT assistants, but acknowledged that this resident did not receive the ordered services and could not explain how this occurred. NF1 confirmed by phone that the resident was admitted with therapy ordered but did not receive therapy during the stay. Reference to National Council of State Boards of Nursing standards indicated that nurses are responsible for implementing patient care orders unless there is a reason to question them.