Surveyors found that the facility did not provide occupational therapy (OT) services as ordered by physicians and outlined in the plans of care for two residents with fractures who required assistance with ADLs. Although the facility assessment and policy indicated that OT would be available and delivered per MDS findings and physician orders, documentation showed that scheduled OT sessions were missed without adequate explanation, and residents received fewer treatments than the three-times-weekly frequency established in their OT evaluations. The Director of Rehabilitation acknowledged that the OT plans of care were not followed and linked the missed sessions to OT staffing issues, while the administrator was aware of ongoing OT staffing problems.
A resident who required assistance with ADLs and had moderate cognitive impairment was care planned for OT involvement and had physician orders for OT evaluation and treatment two times per week. The resident received only an initial OT evaluation, with no follow-up treatment sessions provided, and reported not recalling working with therapy staff. The rehab director confirmed the lack of ongoing OT services and noted reliance on part-time and PRN OT staff while therapy positions were being advertised.
A new therapy company failed to deliver rehab services at the ordered frequency for 3 residents with PT/OT plans of 3-5x/week. Residents with a fractured arm, a left upper leg fracture, and toe amputations reported gaps in therapy, and logs showed missed PT visits, including periods with no PT, while the DOR later confirmed missed PT visits related to lack of PT staff and use of OT to fill gaps.
The facility did not provide timely PT and OT evaluations and treatments as ordered for two residents admitted with complex medical needs, including respiratory failure and post-hip replacement care. One resident waited five days after admission for initial PT and OT evaluations despite orders written at transfer, and reported receiving little therapy. Another resident, admitted after hip surgery and requiring substantial assistance with ADLs, did not receive PT and OT evaluations until several days after admission and ultimately received only one PT and one OT treatment before discharge. Staff interviews revealed that PT staffing was limited to Monday through Thursday, causing residents admitted on Fridays to wait until Monday for therapy, and leadership believed evaluations only needed to be completed within three days of admission.
A resident with orders for PT/OT and a PT plan of care specifying treatment twice weekly did not receive PT services for an 18‑day period. The resident reported not having PT for about two weeks, and review of therapy notes confirmed no PT during that time and no documentation of refusals or missed visits. The PT stated residents are to be seen per their treatment plan and that missed visits should be documented, but no such documentation existed. The rehab director acknowledged the gap in services was due to staffing shortages that prevented scheduling, and the administrator confirmed the expectation that residents receive therapy as ordered.
A resident with a fractured femur, legal blindness, and moderate cognitive impairment did not receive the full number of occupational and physical therapy sessions as outlined in their care plan, receiving significantly fewer therapy visits than ordered before being discharged after insurance coverage ended.
A resident admitted with cellulitis, muscle weakness, and difficulty walking did not receive a physician-ordered PT eval and tx in a timely manner. The resident’s initial PT eval and tx plan was completed five days after admission, rather than within the facility’s expected 24 to 48 hours. Staff stated the delay occurred because the facility did not have enough therapists at the time.
Two residents admitted with fractures did not receive occupational therapy (OT) evaluation and treatment as ordered due to the unavailability of an OT. Although physician orders and provider notes indicated the need for OT, therapy was delayed until an OT became available, and it was unclear if medical providers were notified of the delay. The administrator expected therapy to be provided as ordered but was unaware of the lapse.
A resident with complex medical needs did not consistently receive the physician-ordered frequency of OT and PT sessions. Therapy staff missed sessions without proper documentation or explanation, and staff could not provide records of refusals or reasons for missed treatments.
Failure to provide ordered Speech Therapy services for a resident with dysphagia and cognitive impairment. The resident had an order for ST to evaluate and treat, plus diet modifications and dining supports, but the facility did not have an ST available and no documentation was provided showing the order was addressed. The DON and DOR acknowledged the resident had not been evaluated because the position was still being filled and licensure approval was pending.
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