HospitalInspections.org

Based on review of facility policies and procedures, medical record review, and staff interviews, it was determined that the facility failed to ensure that staff provided physical therapy (PT) and occupational therapy (OT) as ordered for one patient (P) (P#1) of four sampled patients (P#2, P#3, and P#4). Specifically, P#1 was hospitalized from 2/19/25 to 3/22/25 and failed to receive six days of OT and seven days of PT as ordered.


Findings include:


A review of the facility's policy titled "Prioritization of Patient Care," policy # 10153, last revised 3/18/25, revealed that the purpose was to determine prioritization of patient care for all therapy patients when necessary.
1. Patients, unless prohibited by medical status, received assessment and/or treatment as ordered by the physician.


A review of the facility's policy titled "Documentation Guidelines," policy # 24285, last revised 5/5/25, revealed that a patient's refusal of treatment, reason unable to treat patient, if clinician determined treatment should be withheld, cancellation of treatment, or a failure to appear for appointment was documented in the patient's medical record.


A review of the facility's policy titled "Rehabilitation Services Scope of Services - Systems," policy# 14519, last revised 5/5/25, revealed that in-patient clinical services were to be provided at the facility that were ordered by referrals from licensed physicians, non-physician practitioners, physician assistant, advanced practice registered nurse practitioners, and neuropsychologist for all occupational, physical, and speech language pathology therapy.


A review of the medical record for P#1 revealed an order for Occupational Therapy (OT) Acute Treatment dated 2/20/25 for every morning beginning 2/21/25 at 4:00 a.m. The order was discontinued on 3/22/25 at 3:01 p.m.

In addition, a review of "Orders" dated 2/21/25 at 6:24 p.m. revealed an order for Physical Therapy (PT) Acute Treatment beginning 2/22/25 at 4:00 a.m. every morning. The order was discontinued on 3/22/25 at 3:01 p.m.


Further review of the medical record for P#1 failed to reveal documentation of P#1 receiving OT or deferment of therapy on the following dates:
2/22/25
2/23/25
3/9/25
3/14/25
3/19/25
3/20/25

A continued review of the medical record for P#1 failed to reveal documentation of P#1 receiving PT or deferment of therapy on the following dates:
2/22/25
2/23/25
3/2/25
3/5/25
3/9/25
3/16/25
3/19/25


An interview was conducted on 9/10/25 at 1:20 p.m. with Physical Therapist (PT) AA in the facility's conference room. PT AA stated that physicians placed therapy orders after which PT AA assessed the patient, established a plan of care, and set the frequency of the therapy. PT AA explained that if a patient declined to participate in therapy, PT AA explored the reasons, created an alternate plan, and rescheduled. PT AA stated that if both patient and/or family refused, PT AA stated that she always attempted to go back later in the day and see the patient. PT AA said she documented all therapy deferrals in the medical record.


An interview was conducted with Director of Rehabilitation Services and Interventional Pain and Spine (DRS) CC on 9/10/25 1:57 p.m. in the conference room. DRS CC stated that PT and OT therapists were provided with a list of patients to see each day. Her expectations were that therapist should try to see all patients on their scheduled list. If unable to provide therapy to a patient due to time restraints, the therapist should inform their manager at the end of the day. DRS CC said no documentation was completed for the patient who was unable to be seen due to scheduling. DRS CC said that if therapists were unable to see a patient due to refusal by the patient/family or a health concern prevented the patient from participating in therapy, it should be documented in the patient's medical record under deferment.


A telephone interview was conducted with PT DD on 9/10/25 at 2:15 p.m. PT DD explained that if PT was deferred for a patient, documentation was entered in the patient's medical record. In addition, any missed PT visits were also documented accordingly.


An interview was conducted with Manager of Rehabilitation Services (MRS) EE on 9/10/25 at 2:47 p.m.in the conference room. MRS EE's expectations were that therapists try to see all patients on their daily schedule. If a therapist did not have time to see a patient, the therapist should inform their manager at the end of the day. No documentation would be completed in the patient's medical record if the patient was not seen due to scheduling. MRS EE stated a list was collected at the end of each day that consisted of patients who were not seen.
MRS EE continued to reveal that the late therapist could access the list and see the patient if time allowed. The department scheduler would print a list of patients from the automated system each morning for patients who were scheduled for therapy. The patients who did not receive therapy the day prior would be on the printed list and that therapists would prioritize patients by the acuteness of condition and need.
MRS EE stated that if it were not appropriate for a patient to receive therapy, the therapist would document in the deferred notes section of the patient's medical record. In addition, if a patient and/or family member refused therapy services, MRS EE stated that he expected therapist to document the refusal in the patient's medical record.