The facility allowed a respiratory therapist to provide respiratory care without verifying state licensure, despite a job description and a license verification policy requiring a valid, unrestricted state license. Human Resources hired the therapist and did not complete or document required license verification with the state regulatory agency, later confirming the therapist never held a state license during employment. This failure resulted in an unlicensed individual delivering respiratory services to residents and was cited as a deficiency.
Failure to provide ordered RNA services for a resident with cervical myelopathy, bone density disorder, and bilateral hand OA. The resident was cognitively intact but dependent for transfers, lower-body dressing, and personal hygiene. The order summary included ROM to both LEs, an abductor wedge, and a right resting hand splint, but the DSD confirmed missing documentation for several scheduled treatments and stated that if it was not documented, it was not done.
A resident with a history of cerebral infarction, multiple sclerosis, and ataxia, who required assistance with mobility and ADLs, did not receive a physician-ordered PT evaluation and treatment. The resident reported never having PT since admission, and both a CNA and an LVN confirmed they had not observed any PT services provided. Record review showed an active order for PT evaluation and treatment, and the administrator acknowledged that this order was not followed, despite a facility policy requiring provision of PT upon written physician order.
A resident with breast cancer and brain cancer had physician orders for PT and OT evals, but the rehab record contained no documentation that either eval was completed. The DOR confirmed the missing documentation meant the evals were not done, and the facility policy required therapy services to begin with an initial clinician eval initiated within 72 hours of the order.
A resident with spinal stenosis, acute kidney failure, muscle weakness, and significant ADL dependence did not receive ongoing PT/OT services because the facility failed to facilitate use of the resident’s secondary insurance after the primary insurance’s limited coverage ended. PT was discontinued after a short period and the resident was discharged to an RNA program, despite a hospital physician’s recommendation for extended PT/OT and the resident’s expressed desire and potential to benefit from more therapy. The DOR, RN supervisor, and RNA staff acknowledged the resident could have benefited from additional PT/OT, while SS and the DON were unaware that therapy had been interrupted due to insurance and that SS might be responsible for securing additional resources, contrary to facility policy requiring provision or arrangement of needed specialized rehabilitative services.
Failure to Continue Ordered PT and Restorative Services: A resident admitted with a femur fracture, left hip periprosthetic fracture, weakness, and difficulty walking had PT ordered to continue 5x/week for 8 weeks, but the therapy was discontinued and the resident reported no one was assisting with exercises. The DOR confirmed the extended PT order was not followed, the resident remained in the facility, and the resident was not enrolled in RNA/restorative services.
Delayed Start of Restorative Nursing Services: A resident with MS, paraplegia, and muscle wasting/atrophy was discharged from PT and OT, but the restorative nursing referral for therapeutic exercise and ROM was not started right away. The resident reported therapy began late and was concerned about upper extremity strength and mobility, while the DOR and DSD stated the restorative program was expected to begin promptly after the referral was entered.
During a transition from contracted to in-house rehab services, five residents with physician orders and established care plans for PT and/or OT did not receive their prescribed treatments for multiple weeks. Orders for therapy to address muscle weakness, gait and mobility abnormalities, and pelvic issues were in place, but no PT or OT staff were available to evaluate residents or continue existing treatment plans after the contract ended. The ADM and DON confirmed that therapy services were unavailable during this period, that plans of care and orders were not followed, and that physicians were not notified to clarify or adjust treatment orders, contrary to facility policies requiring timely, coordinated, and documented therapy services.
A resident admitted with essential tremor, dysphagia, and a cognitive communication deficit had a physician order and care plan for speech therapy (ST) three times weekly for four weeks following an initial ST evaluation. Despite facility policies requiring that physician orders be carried out, the resident received only the initial evaluation and no subsequent ST treatments, and was not placed on the ordered treatment schedule. The resident later reported expecting ongoing ST for speech but confirmed no further visits occurred, while therapy leadership acknowledged that the ordered visit frequency was not followed.
A RT failed to perform trach care per physician orders and facility policy for a resident with trach and ventilator dependence. During observed care, the RT changed gloves multiple times without HH between changes, attempted double gloving, used NS instead of ordered H2O2 to clean the stoma, and inserted the sterile inner cannula before cleaning the stoma area. The RTM and DON stated the care did not follow the ordered procedure or infection control expectations.
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