Failure to Refer Resident Request for Drop Arm Commode to OT: A resident who became non weight bearing and had intact cognition requested a drop arm commode after she could no longer safely use a standard commode. The DOR, a COTA, told her she did not need the device and suggested using the existing commode or a bedpan instead, without notifying the supervising OT for an evaluation. The resident then used adult diapers for toileting and reported feeling humiliated, angry, and frustrated.
Failure to identify a decline in ADLs and mobility delayed consideration of renewed rehab services for a resident with generalized muscle weakness, morbid obesity, and bilateral knee OA. After OT/PT discharge at maximum potential, later MDS assessments showed the resident still needed substantial to maximal assistance for toileting hygiene and bed mobility, but the RC was not notified of the decline and the DON stated there was no documentation that the physician was notified to consider new PT/OT evaluations.
A resident with quadriplegia, DM, and COPD was ordered RNA passive ROM for all 4 extremities 4 times weekly, but restorative records showed multiple blank days and inconsistent entries for provision or refusal of care. The resident said RNA helped maintain movement, while RNA staff and the DON stated that every session or refusal should be documented in PCC to validate the service was done.
A resident admitted after cervical spinal fusion and with a spinal cord injury did not receive ordered skilled PT five times per week during the first three weeks of admission. Therapy records showed fewer sessions than ordered, and the DOR stated therapist availability might have contributed to the missed sessions, while the DON stated the facility was responsible for providing therapy per the physician order.
A resident with quadriplegia, hypotension, and anxiety disorder was ordered continued PT after discharge, but the authorization request for ongoing therapy was not submitted to the insurance company in a timely manner. The DOR said the recommendation for more PT was communicated to case management, the CM acknowledged the delay, and the ADM stated the request should not have taken that long to submit.
A resident with a history of repeated falls, CVA, and osteoarthritis did not receive PT 5x/week as ordered. The record showed only an evaluation and four PT treatment sessions, while the DOR stated the resident had not been receiving therapy as ordered and the physician had not been notified. The resident and FM both reported that PT was not being provided as expected, and the DON stated the facility must notify the physician when an order cannot be carried out.
A resident with muscle wasting, osteoarthritis, and lack of coordination had ADL deficits and physician orders for PT and OT evaluations, but the evaluations were not completed. The resident stated he could move all extremities but could not sit, walk, or care for himself and needed PT and OT services. The DOR confirmed the ordered rehab evaluations were missed because he was unaware of the orders, despite facility policy requiring therapy services per physician order.
A DOR who was a COTA transcribed PT findings into JMAs for two residents instead of the JMAs being independently assessed by a qualified PT. One resident had Parkinson's Disease, hemiplegia/hemiparesis, and contractures, yet the JMA understated severe ROM limits documented in the PT eval and observed during PROM. Another resident with dementia and lower-extremity limitations had a JMA showing WFL despite PT and bedside observations showing impaired positioning and mobility. The DOR stated she transposed the PT assessment into the JMA and did not know what the impairment levels meant in degrees.
A resident with macular degeneration, neurologic disease, and unsteadiness was receiving PT using a white cane instead of an appropriate walking stick for balance and walking. The DOR stated therapy had been working with the resident on a walking stick, but during observation confirmed the white cane was not a walking stick and was not made for walking; the resident and an LPN stated the cane was used for blindness-related seeing assistance.
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.
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