Failure to Complete Ordered Speech Therapy Evaluation and Lack of Bowel Management Documentation
Penalty
Summary
The facility failed to ensure that a speech therapy evaluation was completed as ordered for a resident with severe cognitive deficits and multiple diagnoses, including myasthenia gravis and pervasive developmental disorder. The resident was admitted for a respite stay and had specific dietary needs communicated by family, such as using a slow flow sippy cup, avoiding milk, and having medications crushed in applesauce. Despite a physician's verbal order for a speech therapy evaluation due to these special diet recommendations, there was no documentation that the evaluation was completed, and the speech therapist confirmed she had not evaluated the resident. The administrator was unable to provide an explanation for the missing evaluation. Additionally, the facility failed to document and implement interventions for bowel management for another resident with Alzheimer's disease, developmental disorder, and iron deficiency anemia, who was receiving multiple medications including opioids and was frequently incontinent. Review of bowel movement documentation over a period showed infrequent bowel movements, but there was no evidence of orders for treatment or intervention attempts related to the lack of bowel movements. The facility was unable to provide a policy related to bowel protocols and monitoring when requested.