Failure to Complete Swallowing Assessment for Resident with Dysphagia Symptoms
Penalty
Summary
The facility failed to provide services that met professional standards of quality by not ensuring a swallowing assessment was completed for a resident who exhibited difficulty swallowing and coughing during meals. The resident, who had diagnoses including Huntington's Disease, altered mental status, and cognitive communication deficit, was observed coughing during meals on multiple occasions. Despite nursing staff and other residents noticing the resident's difficulty swallowing, and documentation in the medical record indicating coughing and swallowing issues, there was no evidence that a swallowing evaluation was performed in a timely manner. The facility's policy required therapy screenings within 48 hours when a change in function was noted, but this was not followed. Speech therapy (ST) notes did not document any swallowing evaluation or address the resident's coughing or choking episodes, even after nursing staff reported the issues. The speech therapist did not assess the resident's swallowing because the resident had already received the scheduled therapy visits for the week, despite the therapy director confirming that additional visits could be provided if needed. The resident's diet was eventually downgraded to mechanical soft after further observation of swallowing difficulties, but a formal swallowing evaluation was still not completed at that time.