HospitalInspections.org

Based on interview and document review, the facility staff failed to ensure they followed the Plan of Care established for one (1) patient (Patient #1).

Findings include:

A review of Patient #1's medical record on 4/29/19 and revealed the following:
Patient #1 was a 28 month old referred by their pediatric office and initially seen for an evaluation on 1/9/19. The pediatric office directive was to evaluate and treat for an "in-toeing gait."

The evaluation revealed Patient #1 had impairments with alignment of bilateral lower extremities (BLE), gait pattern, mild BLE foot pronation and decreased motor skills as appropriate for age. A Peabody Developmental Motor Scales 2 (PDMS2) assessment revealed a raw score of 96 (normal 115 to 123 for age) and percentile score of 9% (50% is normal for age). Per the Treatment Plan, Patient #1 was to be seen once a week for four (4) months.
Patient #1's Treatment Plan included both long term and short-term goals. Long-term goals were ambulation with toes less visible bilaterally for posterior view, descending four (4) steps with RLE (right lower extremity) leading.
Patient #1's short-term goals: tolerance to kinesio tape to BLE or BLE orthotics. , jumping from a 10 inch BLE take-off and landing without external support with SBA (Standby Assist) for safety, jump forward with BLE take-off and landing, ascending four steps without support with LLE (left lower extremity) leading while under SBA for safety and kick a stationary ball six (6) feet with less than 20 degrees deviation.

The referring physician approved the plan on 1/14/19.

On 3/13/19, Patient #1 performed or attempted to perform the following: Attempting scooter board activities and swing but pt (Patient) not participating and only saying "no". Stair navigation with single HR (handrail) and reciprocal step-to pattern with VCs (verbal cues) only. Application of KT (Kinesio tape) to B (both) feet to reduce pronated position. Attempting rolling up/down ramp for oblique strengthening but pt not attempting. Knee walking up ramp in tall kneel for hip strengthening; pt turning around to look at PT (Physical Therapist) while continuing to walk but as PT attempted to reach to stop pt, [Patient #1] began walking faster thinking it was a game and knee walked off edge of ramp falling on L (left) side. Pt began crying, and was consoled by dad with little improvement. PT palpated pt's B wrists, hands, elbows and shoulder but no asymmetries noted. Unable to tell if pt tender to touch on elbow or if [Patient #1] just didn't want to be touched at all. Session ending early due to pt emotional upset.

Staff Member #6 was unavailable for interview due to being out of the country.

Staff Member #1, the physical therapy manager, was interviewed on 4/29/19 at approximately 10:15 A.M. and provided the following information. "I did not know of this incident until 4/1/19. When I found out about the injury, I immediately began an investigation of the event doing a role-play with [Name of Staff Member #6] present and other staff. [Name of Staff Member #6] reported [he/she] lunged to grab the Patient (#1). Had [Name of Staff Member #6] been within arms-reach, they should have been able to grab the Patient (#1).
[Name of Patient] fell off the incline mat at its highest point (nineteen (19) inches) and landed on the mat in front of the incline mat. The therapist (Staff Member #6) was standing next to the wedge and the father was standing at the bottom. The therapist (Staff Member #6) would not have held on to the child because the point of the exercise was to have the Patient perform the activities with as little cueing or hands on as much as possible."

On 4/29/19 at approximately 11:00 A.M., a tour of the area where Patient #1 was during the 3/13/19 incident was conducted. The incline mat was located next to a wall. The mat folds to form a large square. When unfolded (one fold), the matt forms a wedge. It was sitting on top of two tumbling mats (one in the front and one on the side). The wedge measured five (5) feet across, nineteen (19) inches at it's highest point. With the tumbling mats under it, the wedge measured twenty-one (21) and one half inches from the floor. From the top (highest part) of the wedge to the lowest (bottom part), the wedge was approximately five (5) to six (6) feet long.

A policy related to falls was provided by Staff Member #1. The policy (Fall Risk Assessment last revised or reviewed on 9/18) documents... In the outpatient setting, therapist evaluating a client with a diagnosis related to fall risk (e.g., spastic cerebral palsy) will document techniques or equipment needed to reduce fall risk (e.g., gait belt, contact guard assistance). Therapist will also document all caregiver training related to fall prevention. In addition, regardless of diagnoses therapist will provide a safe environment free from trip and slip hazards, and educate caregivers on safety in outpatient areas (e.g. no running in hallways, climbing on stools).

The policy failed to address safety issue for different age groups and what SBA means in providing safety.

Standby Assist is described by, VeryWell Health Orthopedics and Physical Therapy "Assistance With Mobility in Physical Therapy" By Brett Sears, PT
Brett Sears, PT, MDT, is a physical therapist with over 15 years of experience in orthopedic and hospital-based therapy. Medically reviewed by a board-certified physician.
Updated April 05, 2019.

...Stand-by Assist: During stand-by assist, the physical therapist does not touch you or provide any assistance, but he or she may need to be close by for safety in case you lose your balance or need help to maintain safety during the task being performed.