HospitalInspections.org

Based on interview and record review, the facility failed to deliver the ordered frequency of physical therapy (PT) visits as outlined by the developed plan of care for 3 (#s 2, 9, and 10) of 12 patients; which had the potential to contribute to patient #2's decline in ambulatory status from ambulatory with assistance to non-ambulatory. This deficient practice had the potential to affect all patients receiving rehabilitation services by the facility. Findings include:

1. During an interview on 10/11/23 at 11:55 a.m., NF2 stated patient #2 was able to walk with assistance prior to being admitted to the hospital. He stated patient #2 was now completely bed ridden and was discharged on palliative care. NF2 stated he felt this was related to the patient not receiving regular physical therapy while hospitalized.

Patient #2 was admitted from 7/19/23 to 8/17/23. With an admitting diagnosis of weakness, scalp wound, and hardware removal.

Review of patient #2's Physician Progress Note, dated 7/26/23, showed, "...Weakness: PT/OT recommends back to [Assisted Living Facility]. His provider says he can walk 20-40 feet with walker at baseline. Plan: Continue PT/OT while in hospital."

Review of patient #2's Physical Therapy Evaluation, dated 7/22/23, showed: "Mobility: He reportedly does not use a walker and ambulates with handheld assist at his ALF...Plan: To see [everyday] for [physical therapy], 5-7 days/week to address the above interventions."

A review of patient #2's Daily Physical Therapy Notes, from 7/20/23 to 8/17/23, showed the patient received therapy services less than the ordered five to seven times per week as follows:

- For the week of, Monday 7/23/23 to Sunday 7/29/23, the patient was seen by PT three times.

- For the week of, Monday 7/30/23 to Sunday 8/5/23, the patient was seen by PT two times.

- For the week of, Monday 7/25/23 to Sunday 8/12/23, the patient was seen by PT four times.

- For the week of, Monday 8/13/23 to Friday 8/17/23, the patient was seen one time, on 8/14/23.

Review of patient #2's Daily Therapy notes, from 7/20/23 to 8/17/23, did not show the patient met any of the established physical therapy goals.

Review of patient #2's Health record, from 7/19/23 to 8/17/23, did not show documentation for attempted therapy visits and/or a rationale for the missed therapy visits on the following dates: 7/29/23, 7/30/23, 8/1/23, 8/3/23, 8/4/23, 8/5/23, 8/7/23, 8/11/23, 8/12/23, 8/13/23, 8/15/23 and/or 8/16/23.

Review of Palliative Consultation, dated 8/7/23, showed, "History of Present Illness: ...PT notes reviewed, had been seen most recently yesterday by therapy assistant, but was too lethargic to participate after just receiving some IV morphine. Most recent note prior to that that I can see was on 8/2/23, ambulated 7 feet with moderate assist x 2 with PT. Family reports that at baseline at the [Assisted Living Facility], that he ambulates with assistance, occasionally they do use a wheelchair...
Plan: 1...We discussed potential options for care moving forward with continued attempts at therapies and potential TCU stay to see if he can further regain his prior functional abilities versus consideration for solely comfort directed approach. They [Family] are not ready for comfort care approach as of yet. They do desire to give him further opportunity to see if his overall clinical state will improve..."

During an interview on 12/12/23 at 3:40 p.m., staff member E stated it was the expectation for physical therapists to develop a plan of care for each referred patient. Therapists were expected to see the patients based on the patient's developed plan of care and for the determined number of visits per week. He stated it was expected if a therapist was not able to see a patient because the patient was unavailable, the therapist was to return, up to three times in the same day, in an attempt to provide therapy. If a visit was missed, a note would be created as to why the visit was missed.

2. Patient #9 was admitted from 7/28/23 to 8/10/23, with a primary diagnosis of trauma related to motorcycle accident.

Review of patient #9's PT Evaluation, dated 7/31/23, showed, "...Plan: [patient] will continue to benefit from PT services 1-2 times per day to address impairments..."

Review of patient #9's, Daily PT Notes, from 7/31/23 to 8/10/23, showed the patient did not receive PT on the following dates and there was no documentation to report the rationale for the missed visits on 7/31/23, 8/5/23, and 8/7/23.

3. Patient #10 was admitted from 7/23/23 to 8/4/23, with a primary diagnosis of sudden onset abdominal pain related to mesenteric ischemia, small bowel obstruction.

Review of patient #10's PT Evaluation, dated 7/23/23, showed, "...Plan: PT daily to maximize patient level of I. [sic]".

Review of patient #10's Daily PT Notes, from 7/23/23 to 8/4/23, showed the patient did not receive PT on the following dates: 7/26/23, 7/27/23, 7/28/23, 7/29/23, and 7/30/23. There was no documentation noted to report the rationale for the missed visits on 7/26/23, 7/28/23, and 7/29/23.

Review of patient #10's Daily PT Note, dated 7/31/23, showed, "...The [patient] reported feeling weaker today and was nervous about going home."

Review of patient #10's Daily PT notes, from 7/23/23 to 8/4/23, did not show the patient met any established therapy goals.