Failure to Develop Person-Centered Care Plan for Speech Therapy Needs
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who had been admitted with diagnoses including encephalopathy, muscle weakness, and gait abnormalities. Despite a physician's order for speech therapy (ST) to address dysphagia and cognitive-communication deficits, and a detailed ST evaluation outlining the resident's needs and goals, no ST care plan was initiated or incorporated into the resident's comprehensive care plan. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and significant dependence on staff for daily activities, further emphasizing the need for individualized care planning. Interviews with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) confirmed that the absence of an ST care plan meant staff lacked guidance on how to address the resident's specific needs related to dysphagia and cognitive-communication deficits. The facility's policy required care plans to be reviewed and revised with the onset of new problems or changes in condition, but this was not followed. The MDSC acknowledged that not adhering to the policy could affect the resident's quality of care and that the facility was not providing the necessary direction for staff.