Health inspection·September 22, 2023

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide physical therapy (PT) services to a resident with ordered rehab services. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for physical therapy. The findings include: On 9/22/23 at 9:46 AM, R1 said he started getting physical therapy a few days ago. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility with diagnoses including fracture of vertebrae, psychosis, dementia, difficulty in walking, age-related physical debility, lack of coordination, fall, and dysphagia. R1's MDS (Minimum Data Set) dated 8/2/23 shows R1 was cognitively intact and required supervision for eating, and extensive assistance for bed mobility, transferring, dressing, toileting, and personal hygiene. On 9/22/23 at 7:45 AM, V4 (Family Member) said R1 went to the neurologist's office on 9/13/23 and got an order for physical therapy. V4 said she gave the nurse the paperwork with the orders and the nurse forgot about it and did not tell anybody about it. V4 said R1 should have started physical therapy on 9/13/23. V4 said R1 only began getting therapy on 9/21/23 after R1's family member notified the facility. On 9/22/23 at 11:57 AM, V7 (LPN/Licensed Practical Nurse) said R1's family member gave her the order on 9/13/23 and she put the order into the EMR. V7 said she put the paper order into the scan box to be scanned into the computer on 9/13/23. V7 said she did not call therapy to let them know R1 had a new order for therapy. On 9/22/23 at 11:41 AM, V6 (Program Manager of Rehab) said R1's family member came and spoke to her on 9/19/23. V6 said R1's family member told her R1 had a neurology appointment on 9/13/23 and the doctor had ordered physical therapy. V6 said she did not know R1 needed rehab services until she spoke to the family member on 9/19/23. V6 said if she had known R1 had an order for PT (Physical Therapy) on 9/13/23, she would have evaluated him by 9/14/23. V6 said the physical therapists evaluate the residents within 24 hours of receiving the order. V6 said after she spoke to R1's family member, she saw there was an order put in on 9/13/23 to evaluate and treat by the primary care doctor for the facility. V6 said usually when a resident gets an order from a specialist for therapy, the nurse puts the order into the computer and then notifies the therapy department via call or placing the order in her mailbox. V6 said without the nurse notifying them, there was no way the therapy department would be aware of new orders for therapy. Page 1 of 2 145711 145711 09/22/2023 Bella Terra Elmhurst 420 West Butterfield Road Elmhurst, IL 60126

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/22/23 at 12:06 PM, V8 (LPN) said if a resident goes to an appointment and comes back with orders for therapy, the floor nurses put the order in the EMR and give the script to therapy to notify them that they have an order to start therapy. V8 said they notify the sub-acute manager as well. V8 said therapy would not know about the orders without the floor staff notifying them. On 9/22/23 at 12:12 PM, V9 (Post Acute Unit Manager) said it was the expectation that the floor nurses give the new therapy orders to the manager, and they hand it over to the therapy department to notify that there is an order. V9 said she goes right away to let the therapy department know about new orders. On 9/22/23 at 12:29 PM, V10 (Guest Services Director) said the documents are provided to the therapy team regarding updates on therapy and then therapy goes to see the resident the same day or next day. V10 said V4 (Family Member) called V10 last week to ask when R1 was going to be evaluated by therapy and V10 said he told her he was unable to provide her the information. V10 said therapy should do the evaluation within the first 24 hours of receiving an order and then they let the families know whether or not the resident would receive therapy. On 9/22/23 at 12:18 PM, V2 (DON/Director of Nursing) said it was the expectation that the nurse puts the order into the EMR and then notifies therapy. V2 said the nurse had to notify therapy. R1's POS (Physician Order Sheet) shows an order on 9/13/23 for Physical Therapy evaluate and treat. The POS also shows an order for Physical Therapy to see pt [patient] 3x (times) per week for 4 weeks for eval with an order date on 9/20/23. The facility provided an order from V3 (Doctor) dated 9/13/23 which shows Physical Therapy External-OP. Instructions: Services to be performed by an external authorized facility. The facility's Physician Orders policy reviewed on 7/28/23 shows It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance with the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS (Physician Order Sheet). Physician orders will be carried out at a reasonable time. The facility's undated Therapy Evaluation policy shows Residents who are deemed appropriate for a PT, OT (Occupational Therapy), and/or ST (Speech Therapy) evaluation through screening or referral will be evaluated once a physician order is obtained. Evaluation will be completed by a registered therapist as soon as possible after receipt of physician order. 145711 Page 2 of 2