HospitalInspections.org

New Deficiency

Based on medical record review, staff interview, and review of facility protocol on 4/15/15, it was determined that the facility failed to implement its protocol for completion of physical therapy evaluations in two (2) of four (4) medical records reviewed (Medical Records #8 and #9).

Findings include:

Reference: The Patient Evaluation, Assessment and Treatment protocol states "Initial Evaluation 1. Upon receipt of the Rehabilitation Department P.T. referral for Physical Therapy Services signed by a physician, the client will be evaluated for Physical Therapy within 5 [five] working days."

1. Review of Medical Record #8 indicated the following:

a. An ANCILLARY REHABILITATION SERVICES CONSULTATIONS form for Physical Therapy for the patient's right shoulder pain, signed by the ordering physician on 2/25/15.

b. The REHABILITATION SERVICES PHYSICAL THERAPY EVALUATION form indicates the PT evaluation was completed nineteen (19) working days later on 3/24/15 at 10:40 AM.

2. Review of Medical Record #9 indicated the following:

a. A physician order dated 3/3/15 at 3:00 PM to refer to Physical Therapy.

b. A COMPREHENSIVE MEDICAL PROGRESS NOTE dated 3/3/15 at 3:00 PM indicated the patient had low back pain and strain, and was referred to Physical Therapy for further evaluation and treatment.

c. An INTERDISCIPLINARY PROGRESS NOTE dated 4/15/15 at 9:45 AM indicated the patient was evaluated in the PT department. The PT evaluation was completed thirty (30) working days after the physician order for PT.

4. The PT evaluations of Patient #8 and Patient #9 were not completed in 5 (five) working days, as per the above referenced protocol.

a. Staff #28 stated in interview that Patient #9 was out on a brief visit, but was unable to report for what time period.