HospitalInspections.org

Based on review of the patient's medical record, documentation, and interviews, it was determined that the Physical Therapist performed a procedure without a physician's order.

Findings include:

Review of "White Mountain Regional Medical Center Physician Referral Form," dated 7/15/09, revealed: "...Physical Therapy...Diagnosis...R (right) Femur Nonunion...ROM (range of motion) 0-30 degrees...WB (weight bearing) as tol (tolerated)...."

Review of "PHYSICAL THERAPY PRESCRIPTION," dated 8/14/09, revealed: "...Tendon achilles stretches...DX...Planter fascitis...."

Review of "White Mountain Regional Medical Center Progress Report," revealed:

8/17/09: "...S: Pt (patient) RT (return) from Dr (doctor) this morning stating the Dr has released her to bend knee 90 (degrees)...Also, RTC (return to clinic) c (with) script for treatment of plantar fascitis (sp)...O: Phoned Dr office c question...0-90 (degree) ROM? (range of motion)...Dr not in office today left him message...PROM (progressive range of motion) 10-75 (degree)...A: Pt tol ROM activities fair...P. Cont (continue)...."

8/20/09: "...S: States not feeling like doing HEP (home exercise program) last pm 2 (secondary) to HA (headache)...O: No word from Dr's office...phoned again today to ask questions above...AROM (active range of motion) 0-60 (degrees)...PROM 0-65 degrees...A. Pt tol RX (prescription) well...P. cont...."

The Physical Therapist (PT) verified, during interview conducted on 4/7/10, that he always has a script before doing any procedure, and maybe the script to bend the knee 0-90 degrees was lost or there never was one.

Dr. verified, during an interview conducted on 4/23/10, that on 8/14/09, he ordered only AROM to cover 0-90 degrees, where the patient goes as far as she can, just let her progress. The PA, was to relay the order to the PT., but the Dr. doesn't know if PT was notified.

The PA, verified, during an interview conducted on 4/30/10, that on 8/14/09, the Dr. did give him an order for AROM 0-90 degrees. He further relayed the order verbally to the PT, on 8/14/09. There is nothing in the chart, no prescription, but "I do talk to (PT) on a weekly basis."

There was no documentation that the PT had an order to perform only AROM 0-90 degrees on 8/20/09.