HospitalInspections.org

Based on record review and interview, it was determined the facility failed to ensure the Physical Therapist completed Therapy Evaluation as ordered or per request. This affected 2 of 3 medical records reviewed (Medical Records # 4 and 6) with orders or request for a Physical Therapy Evaluation and had the potential to affect all patients served by this facility.

Findings include:

1. Medical Record (MR) # 4 was admitted to the facility on 4/14/15 with a diagnosis of Dementia with Behavior Disturbances.

Review of the physician's orders dated 4/22/15 revealed orders for Physical Therapy to evaluate today 4/22/15.

Review of the Physical Therapy notes revealed an evaluation was not completed until 4/24/15.

An interview was conducted with Employee Identifier (EI) # 1, Director of Hospital Quality on 4/30/15 at 10:15 AM. EI # 1 verified the above.

2. MR # 6 was admitted to the facility on 4/22/15 with a diagnosis of Dementia with Behavior Disturbances.

Review of the medical record revealed a referral for Physical Therapy due to recent falls dated 4/22/15. There was no documentation an evaluation was completed for this evaluation.

Further review of the medical record revealed another evaluation dated 4/26/15 due to recent falls, poor posture sitting or standing, and needs more help with walking, or is not safe.

During a tour of the facility on 4/28/15 the surveyor did see the Physical Therapist perform the patient.

An interview was conducted with EI # 1 on 4/30/15 at 10:20 AM. EI # 1 verified the above.

Tonya Blankenship, RN

Based on record review and interview, it was determined the facility failed to provide Individual Therapy as ordered in 1 of 1 record reviewed with ordered daily Individual Therapy. This affected Medical Record (MR) # 2 and had the potential to affected all patient served by this facility.

Findings include:

1. MR # 2 was admitted to the facility on 4/13/15 with a diagnosis of Major Depression with Suicidal Ideation.

Review of the physician's orders dated 4/13/15 revealed an order for Individual Psychotherapy daily.

Review of the medical record on 4/30/15 revealed Individual Psychotherapy notes dated 4/14/15, 4/15/15, and 4/16/15. Further review of the medical record revealed no documentation of further Individual Psychotherapy notes or a physician's order to discontinue the Individual Psychotherapy.

An interview was conducted with Employee Identifier (EI) # 1, Director of Hospital Quality on 4/30/15 at 10:00 AM. EI # 1 verified the above.

Tonya Blankenship, RN