Inaccurate Documentation in Speech-Language Pathology Notes and Care Plan
Penalty
Summary
The facility failed to ensure that a resident's speech-language pathology treatment notes and care plan contained accurate information. The resident, who had multiple diagnoses including dysphagia, gastrostomy, gastroesophageal reflux disease, and hemiplegia, had a physician order for a regular diet with honey-thick liquids. However, a review of the speech-language pathologist's treatment notes over a period of several weeks documented inconsistent and incorrect information, such as indicating the resident was on a mechanical soft diet with nectar thick liquids and at times listing thin liquids, which did not match the physician's order or the dietary meal ticket. The speech-language pathologist acknowledged during an interview that the documentation was incorrect and that the resident was actually on a regular diet with honey-thick liquids, as confirmed by the dietician. Additionally, the resident's care plan inaccurately described the resident as a messy eater who refused to eat or resisted feeding, with interventions focused on providing privacy due to messiness. Interviews with the assigned LPN and CNA revealed that the resident preferred to eat alone in his room and was able to feed himself independently, contradicting the care plan's statements. The RN/Unit Manager also confirmed that the care plan was incorrect, stating the resident was not a messy eater and simply preferred privacy during meals.