ALBANY, IN - A federal inspection at Albany Health Care & Rehabilitation Center documented serious care coordination failures that left a paralyzed resident without prescribed therapeutic services for months.
Paralyzed Resident Denied Prescribed Care
Federal inspectors found that Resident 73, who experienced paralysis from the chest down, was discharged from physical therapy in October 2024 with specific recommendations for ongoing restorative care. Despite therapy staff recommending passive range of motion exercises and training a specific aide to provide these services, the resident never received the prescribed care.
The resident told inspectors he had not received any restorative care or passive range of motion exercises on his lower extremities while waiting for insurance approval for additional therapy. He expressed concern about losing progress he had made during his initial therapy sessions.
Medical records showed the resident's muscle spasms increased significantly after therapy ended, requiring his baclofen medication to be increased from three times daily to four times daily. He also required additional medications to manage constipation, a common complication in paralyzed patients.
Communication Breakdown Between Departments
The inspection revealed a critical breakdown in communication between the facility's therapy and nursing departments. A Physical Therapy Discharge Summary dated October 4, 2024, clearly recommended that Resident 73 be enrolled in the Restorative Nursing Program for passive range of motion exercises.
The therapy staff completed a formal Therapy Discharge Recommendation form specifying one set of 20 repetitions of slow passive range of motion exercises due to the resident's spasticity. This form was provided to the Rehabilitation Director, who then gave it to the MDS Coordinator responsible for assigning residents to restorative aides.
However, when the original MDS Coordinator left employment, this critical information was never transferred to the replacement coordinator. The new MDS Coordinator reported she had never received the therapy recommendations and confirmed the resident was not on her list for restorative care services.
Medical Consequences of Delayed Care
Passive range of motion exercises are essential for paralyzed patients to prevent contractures, which occur when muscles and joints become permanently fixed in bent positions. Without regular movement, paralyzed limbs can develop permanent deformities that cannot be reversed.
The resident's increased muscle spasms, documented through his need for higher medication doses, indicated his condition was deteriorating without proper care. Spasticity in paralyzed patients typically worsens without consistent stretching and positioning, leading to pain and further functional decline.
A Restorative Aide confirmed during the inspection that the resident was at risk for decreased range of motion and contractures due to his paraplegia, emphasizing the medical necessity of the recommended interventions.
Facility Policy Violations
The facility's own policy, revised in March 2022, specifically required ensuring that residents with limited range of motion receive appropriate treatment and services to prevent further decline. The policy also mandated that residents with limited mobility receive appropriate services and assistance to maintain or improve mobility with maximum independence.
Despite having clear policies and receiving specific therapy recommendations, the facility failed to implement the prescribed care for over three months. The resident's clinical record showed no documentation of any restorative services being provided during this period.
Additional Care Planning Deficiencies
Inspectors also found the facility failed to invite family members to participate in care planning meetings. Resident 34's representative, who visited two to three times weekly, reported being invited to only one care plan meeting despite facility policy requiring ongoing family involvement.
The facility's Social Services Designee acknowledged discussing care with the representative during visits but failed to document formal invitations to care conferences as required by policy.
Fall Prevention Failures
A separate incident involved Resident 129, who experienced multiple falls despite being identified as high risk. The severely cognitively impaired resident fell six times within 10 days of admission, including one fall that resulted in a head laceration requiring sutures and a wrist fracture.
While the facility implemented various safety measures including bed and chair alarms, floor mats, and proper footwear, the repeated falls demonstrated inadequate supervision for this high-risk resident. The Director of Nursing acknowledged that pressure alarms should not replace direct supervision for fall-prone residents.
Physician Notification Oversights
Inspectors also documented failure to notify physicians of significant changes in residents' conditions. Resident 72 experienced a 10.24% weight loss over nearly six months, including an 8.69% loss in a single week, without physician notification.
The resident's weight dropped from 107.4 pounds in July 2024 to 92.5 pounds by December 2024. Despite facility policies requiring immediate physician notification for significant health changes, no documentation existed showing the physician was informed of this concerning weight loss.
Facility Response and Industry Standards
The facility acknowledged these deficiencies during the inspection process. Staff members confirmed that therapy recommendations should have been implemented by the previous MDS Coordinator but were not carried out due to the communication breakdown.
Current facility policies align with federal requirements for restorative care, physician notification, and family involvement in care planning. The violations represent implementation failures rather than policy deficiencies.
Long-term care facilities are required to maintain comprehensive care coordination systems to ensure therapeutic recommendations are followed and family members remain involved in care decisions. These requirements exist specifically to prevent the types of care gaps documented at Albany Health Care & Rehabilitation Center.
The inspection findings highlight the critical importance of effective communication systems between departments in nursing homes, particularly during staff transitions that could disrupt continuity of care for vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Albany Health Care & Rehabilitation Center from 2025-01-14 including all violations, facility responses, and corrective action plans.
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