Failure to Communicate and Implement OT Referral After Orthopedic Surgery
Summary
A facility failed to communicate and implement an Occupational Therapy (OT) referral ordered by an Orthopedic Surgeon for a resident who had undergone open reduction internal fixation (ORIF) surgery for a right olecranon fracture. The OT referral, which included instructions for range of motion (ROM), pain and edema control, a home exercise program, and splint removal for hygiene and active ROM, was not relayed to the therapy department. The referral order was scanned into the resident's electronic health record under a different tab from other orthopedic information, resulting in it not being reviewed or acted upon by nursing or therapy staff. The resident, who had severe cognitive impairment and required maximal assistance with upper body dressing and personal hygiene, did not have her splint removed or receive OT evaluation and treatment as ordered. The splint remained in place for nearly two months, and the resident was not evaluated by OT until over three months after the initial referral. During this period, the resident developed two pressure ulcers on the right elbow, one of which exposed surgical hardware and became infected, ultimately requiring surgical intervention for hardware removal and intravenous antibiotics for MRSA. Interviews with facility staff, including the DON, Therapy Director, and Medical Director, confirmed that the OT referral was not communicated or implemented due to breakdowns in the process for handling outside provider orders and documentation. The Orthopedic Surgeon and Therapy Director both stated that the resident should have received OT services as ordered, and the lack of therapy and splint removal contributed to the development of pressure wounds and infection. The deficiency affected one resident reviewed for therapy and resulted in significant harm.
Removal Plan
- Administrator and Director of Clinical Services reviewed all resident orders with outside appointments to ensure they were in place and correct.
- Therapy Director completed an audit of all current facility residents with therapy orders to ensure the correct physician ordered treatment was in place.
- Ad Hoc QAPI meeting conducted to review and determine root cause of the deficient practice.
- Education implemented on who will be responsible for ensuring the referral form is brought back to the facility when a resident has an outside appointment so new recommendations or orders can be implemented.
- Unit Manager will be responsible for ensuring the referral form returns with the resident; if it is the weekend or after hours, the hall nurse will be responsible.
- Transporter will notify the Unit Manager the resident is back from the appointment and will give her any paperwork at that time.
- If there is no referral form, the Unit Manager will call the physician office to obtain a copy of the form.
- Director of Clinical Services provided education to the Administrator, DON, Transportation driver and ADON on new procedures for handling outside appointment paperwork and therapy referrals.
- Unit manager, or designee, will be responsible for entering orders and ensuring any therapy referrals are received by therapy.
- DON will have a list of resident appointments and will follow up with the Unit Managers to ensure all referral forms have been returned and reviewed, with any new orders entered into the medical record.
- Nurse Aides that accompany a resident to an outside appointment are there to care for the resident; the Transportation Driver will be responsible for ensuring any paperwork, and the referral form, are returned to the Nurse Manager or hall Nurse.
- Unit Manager was educated that when a family member signs the resident out for an outside appointment, they are to follow up with the family when they sign the resident back into the facility to ensure all paperwork has been given to the nurse for review.
- Unit Managers, or designee, will be responsible for taking any therapy referral orders for new admissions to the therapy department on the day of admission.
- DON and ADON provided education to all facility Licensed Nurses and Nurse Aides on new procedures for handling outside appointment paperwork and therapy referrals.
- Current facility Licensed Nurses and newly hired nurses not received education will not be allowed to work until the education has been completed.
- DON will utilize an active employee list to track completion of education and validate the post education written test was completed and passed.
- Education will also be included during orientation for newly hired facility Licensed Nurses, Nurse Aides, and Transportation drivers, to be completed by Director of Nursing or Nurse Manager.
- Administrator and Director of Nursing will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged noncompliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to provide ordered PT services after fall screenings. A resident with repeated falls, intact cognition, and wheelchair use had care plan interventions for therapy screening as indicated. After two post-fall therapy screens, PT was recommended, but therapy did not start. Interviews showed the DOR left a message about copay assistance and did not follow back up, while the resident, family, and PT EE all reported no therapy had begun.
A resident with generalized muscle weakness, mobility and ADL dysfunction had a care plan and physician/NP orders for PT/OT to improve function, but did not receive any therapy for an 11‑day period after services stopped despite an extended stay and an appeal of discharge. The resident, who required staff assistance with most ADLs and used a wheelchair, reported not receiving therapy after the appeal, while the PT confirmed the resident had not met goals and still needed to improve stair navigation before going home. The Rehab Director acknowledged awareness of the appeal, confirmed the absence of therapy during this period, and stated the resident would experience physical decline without those services, demonstrating a failure to provide rehabilitative services as care‑planned and ordered.
The facility failed to provide ordered PT, OT, and SLP services and to complete timely therapy evaluations for several residents. One resident with a stroke and fall history was ordered PT, OT, and SLP; PT was delivered less frequently than prescribed, SLP treatments were not documented after being ordered, and OT evaluation occurred weeks late with only limited OT sessions provided. Another resident with diabetes and protein-calorie malnutrition was discharged from the hospital with a mechanical soft diet and SLP orders but did not receive an SLP assessment for over two weeks and remained on modified textures until then. A third resident with muscle weakness had an OT order but did not receive an OT evaluation for more than two months and reported never receiving OT, which was corroborated by multiple CNAs and an RN. A fourth resident with an anoxic brain injury and femur fracture had an orthopedic PT order that was never acknowledged or communicated to therapy, and no PT was provided. Staff, including the Administrator and rehab leadership, confirmed these lapses and delays in therapy services and evaluations.
A resident admitted for rehab with muscle weakness and unsteadiness had PT and OT care plans and orders for treatment five times per week, but therapy logs showed missed PT/OT sessions on two days with no documented reason. The Director of Rehabilitation confirmed the resident received therapy only three of five days over two consecutive weeks, contrary to the plan of care, and could not explain or document why sessions were missed. The resident and the resident’s representative reported that the resident did not receive therapy as expected, that therapy minutes were insufficient, and that services were not tailored to the resident’s needs, including use of group therapy despite the resident’s stated preference against it.
Failure to Provide Recommended OT Services: A resident with spastic hemiplegia, contractures, weakness, and cognitive impairment was assessed by OT as having difficulty with grooming, hygiene, and a right-hand contracture, and continued OT was recommended. The funding request was denied by the Administrator, and the resident later reported worsening hand contracture and pain after therapy stopped.
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.
Failure to Provide Ordered PT Services After Fall Screenings
Penalty
Summary
The facility failed to provide specialized rehabilitative services for Resident #67, a male resident with a diagnosis of repeated falls. His significant change of status MDS, dated 02/27/26, reflected that he made himself understood and understood others, had a BIMS score of 13, used a wheelchair, and was independent with self-care abilities and mobility. His comprehensive care plan identified him as at risk for injury related to falls and at risk for impaired mobility related to bone density and structure, with interventions that included therapy screening as indicated. Record review showed Resident #67 had a therapy post-fall screen after a fall on 03/10/26, and PT was recommended. A second therapy post-fall screen after another fall on 03/20/26 also recommended PT. The order summary report reflected an active physician order for PT/OT/ST screen as needed with a start date of 01/30/26. During interview, Resident #67 stated therapy had not started. The DOR stated she called and left a message regarding copay assistance, but did not follow back up, and stated she was not informed by nursing staff that Resident #67 had declined after the later fall. Additional interviews reflected that the family member had asked about therapy when Resident #67 was first admitted and later stated she would pay the copay, but she did not hear anything back. The Director of admission stated she had discussed therapy with the PT EE, while the PT EE stated he was waiting on approval from the DOR to start services. The DON and Administrator stated they expected therapy services to be available as requested and that follow-up should occur to confirm family approval. The facility policy stated therapy services would be available to assist residents in maintaining maximum independence, that residents would be screened upon admission and as needed, and that residents and/or representatives would be involved in the therapy plan.
Failure to Provide Ordered Rehabilitation Services During Extended Stay
Penalty
Summary
The facility failed to provide specialized rehabilitative services according to the resident’s care plan and clinical assessments. The care plan initiated on 3/25/26 identified a focus for rehabilitation services with a goal to improve the resident’s current level of function, and included an intervention to provide therapy services per physician orders. The admission MDS documented that the resident had no cognitive or communication impairment but required staff assistance with most ADLs and was wheelchair bound. On 4/16/26, an NP documented that the resident had generalized muscle weakness, mobility and ADL dysfunction, and was at risk for functional impairment without pain control and PT/OT services. The attending physician also documented on 4/16/26 that the resident was in extensive need of therapy and not ready for discharge home. Despite these assessments and the active care plan for rehabilitation, therapy notes showed that the resident did not receive any therapy services after 4/16/26. The record and interviews showed that the resident’s insurance coverage was initially ending, the resident agreed to go home, then appealed the decision and was granted additional days of coverage and an extended stay. The Social Services Director confirmed that the resident’s stay was extended and that the resident appealed and was granted to remain until 4/22/26. The resident reported being granted an extended stay and stated they had not received therapy since 4/16/26, despite feeling they needed more therapy to be safe at home. The PT stated the resident had not met therapy goals and needed to improve stair navigation before going home, and acknowledged that although services were approved until 4/23/26, insurance sometimes stopped services. The Rehab Director confirmed that the resident had not received therapy since 4/16/26, was aware of the appeal, and stated that the resident would experience physical decline without therapy services for 11 days, confirming a gap in providing ordered and care-planned rehabilitative services during the appeal and extended-stay period.
Failure to Provide Ordered PT, OT, and SLP Services and Timely Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services as ordered for multiple residents. One resident admitted with a stroke and history of falls had physician orders for PT, OT, and SLP evaluations and treatments as indicated. PT assessed this resident for therapy five times per week for a defined certification period, but documentation showed PT was only provided four times per week during several weeks. SLP initially did not recommend services, but after a subsequent assessment on 1/19/26, the resident was ordered SLP twice weekly for 60 days, with no documentation of any SLP treatments after that date. OT did not evaluate this resident until 42 days after admission, and although OT determined a need for services five days per week for 60 days, the resident received OT on only a limited number of dates before discharge. The Administrator confirmed that therapy services were not provided as prescribed and that evaluations were not completed within the expected timeframe. Another resident, with diagnoses including diabetes and mild protein-calorie malnutrition, was transferred from the hospital with orders for a mechanical soft diet and SLP evaluation and treatment. The SLP assessment did not occur until 17 days after readmission, during which time the resident continued on mechanical soft diet textures. The resident reported it took about a month to get off puree foods and stated they were told the facility needed to hire more SLP staff before an assessment could be completed. The Regional Director of Rehabilitation and the Administrator both confirmed the delay in SLP assessment and were unable to explain why the evaluation was not completed sooner, despite existing orders for SLP evaluation and treatment. A third resident admitted with muscle weakness had physician orders dated 2/12/26 for OT evaluation and treatment, but the OT evaluation was not completed until 4/20/26. The admission MDS indicated the resident had not received any therapy services in the seven days prior to that assessment. The resident stated they had not received OT and were interested in therapy to help them leave the facility. Multiple CNAs and an RN reported they had never observed this resident working with therapy since admission. The Rehabilitation Director acknowledged the OT evaluation was not timely and cited difficulty maintaining Certified Occupational Therapy Assistants. In a fourth case, another resident with anoxic brain injury and a right femur fracture had an orthopedic order for PT, but the clinical record contained no evidence that the PT order was acknowledged, clarified, or communicated to the therapy department, and the resident did not receive PT. An RN case manager stated the order must have been missed and confirmed that therapy was not provided.
Failure to Provide Ordered PT/OT and Document Missed Therapy Sessions
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered for one resident admitted for rehabilitation with diagnoses of muscle weakness and unsteadiness on feet. The resident’s care plan, initiated shortly after admission, identified a rehabilitation focus with skilled PT and OT interventions, and physician orders specified PT and OT to evaluate and treat. The OT plan of care called for treatment five times per week for 60 days, and the PT plan of care called for treatment five times per week for 30 days. Review of the Service Log Matrix showed that the resident did not receive individual PT or OT on two specified dates, despite the plan of care requiring therapy five days per week. The Director of Rehabilitation confirmed that the resident missed PT/OT on those two dates, that the plan of care was for five days a week, and that the resident only received PT/OT three out of five days for two consecutive weeks. The resident and the resident’s representative reported concerns that the resident was not receiving the allotted amount of therapy time and that therapy was not tailored to the resident’s specific needs. The representative stated the resident was weaker upon discharge than at admission and that the family sought transfer to another facility for PT after expressing concerns without improvement. The resident reported not receiving any PT during the first week, receiving PT only after questioning staff, and that when PT was provided it lasted 30–40 minutes and included group therapy that was counted as PT despite the resident’s preference against group therapy. The Director of Rehabilitation stated she did not know why therapy was missed on the two identified dates and that no reasons were documented, although such reasons were typically recorded. The DON stated her understanding that if therapy was missed, staff should attempt to reschedule so that residents did not miss needed therapy, and the current Administrator stated her expectation that residents receive the therapy they are supposed to receive to reach their maximum potential.
Failure to Provide Recommended OT Services
Penalty
Summary
The facility failed to provide or obtain specialized rehabilitative services for one resident when Occupational Therapy was recommended but not approved. The resident was admitted with multiple diagnoses including spastic hemiplegia affecting the right dominant side, contractures, gait and mobility abnormalities, muscle wasting and atrophy, generalized weakness, and sequelae of cerebral infarction. The resident’s quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and the care plan identified impaired mobility and ADLs with a need for assistance related to cognitive and functional decline, right-sided hemiplegia, personal care needs, muscle wasting, and weakness. The quarterly Therapy Screening Form documented difficulty performing ADLs, including grooming, along with joint limitations and contractures. The Occupational Therapist noted difficulty completing grooming and hygiene tasks and a right digit contracture, and OT was recommended. A Rehabilitation Therapy Funding Information Form was completed and sent for administrator approval, but the administrator denied the request, documenting that it was not approved at that time. The Director of Rehabilitation stated that the resident was screened quarterly, that the last screening recommended continued OT services based on the resident’s right-hand contracture and decline in grooming and hygiene, and that if the funding form was not approved there was nothing more that could be done to assist with therapy services. During observation, the resident was sitting on the side of the bed looking distressed, with the fingers of the right hand contracted and the pinky finger digging into the palm. The resident stated that therapy had been helping, that the fingers had been straightening out, and that pain had improved, but therapy was stopped because the resident was told services were no longer approved. The Administrator stated he denied the funding form after his own review and said he did not see a reason to continue OT services, later acknowledging that the Therapy Screening Form contained the diagnosis and reason for services, including decline in grooming, hygiene, and right-hand contracture.
Failure to Provide Ordered Occupational Therapy Services as Planned
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically occupational therapy (OT), as ordered by physicians and outlined in residents' plans of care for two residents. The facility assessment indicated that OT services were available seven days per week and that staffing would be sufficient to meet resident needs. Facility policy stated that specialized rehabilitative services, including OT, would be provided upon written physician order and as indicated by the MDS. For one resident with right shoulder and leg fractures who required extensive assistance with ADLs, the physician ordered skilled OT evaluation and treatment, and the OT evaluation established a plan of care for OT three times per week. However, OT treatment records showed the resident was seen only once during one specified week and twice during the following week, with missed scheduled sessions and no documented reasons other than a remark of "Others." The resident and the resident’s representative both reported that OT was not provided as frequently as planned, and the resident expressed that the rehabilitation services were not enough to help them return to their prior level of function. A second resident, who had a left arm fracture with muscle injury and required staff assistance with ADLs, also had a physician order for skilled OT evaluation and treatment, with an OT evaluation establishing a plan of care for three OT sessions per week. OT treatment notes showed this resident was seen only twice during a specified week, with another scheduled OT session missed and no documentation in the therapy record explaining the missed visit. The Director of Rehabilitation acknowledged that both residents’ OT plans of care were not followed and attributed the missed OT sessions to OT staffing issues. The administrator stated awareness of the facility’s OT staffing problems. The survey findings concluded that the facility did not ensure specialized rehabilitative services were provided as required by physician orders and residents’ plans of care, placing residents at risk of not attaining, maintaining, or restoring their highest practicable level of well-being.
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