Failure to Provide Timely Speech Therapy Evaluation for Swallowing Disorder
Penalty
Summary
A deficiency occurred when a resident admitted with diagnoses including dysphagia, anxiety, depression, and failure to thrive did not receive timely speech therapy services as ordered to address a swallowing problem. The resident was admitted with a physician's order for a speech therapist to evaluate and treat as indicated, as well as an order for a pureed texture diet. Despite these orders, the speech therapy evaluation was not initiated promptly. The facility's policy required evaluations to be initiated within a reasonable time following receipt of a physician's order, but the order for speech therapy, entered on 5/28/2025, was not communicated to the therapy department until 6/9/2025. As a result, the resident did not receive a speech therapy screening until 6/11/2025. The delay was due to a breakdown in communication between nursing and the therapy department. Nursing staff were responsible for entering orders into the electronic medical record and communicating new orders to therapy via a screening request form. However, the Rehab Director and the speech therapist were unaware of the order until the resident expressed dissatisfaction with her food texture, prompting nursing to submit the screening request. During this period, the resident reported frustration with the pureed diet, had unclear speech, and exhibited drooling with loss of saliva control. Staff interviews confirmed that the communication process failed, resulting in the resident not receiving the ordered evaluation in a timely manner.