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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