Failure to Implement Speech Therapy Orders for Resident with Dysphagia
Penalty
Summary
Facility staff failed to implement physician-ordered speech therapy (ST) services for a resident with Parkinson's disease and dementia who exhibited signs of dysphagia, including coughing and choking during meals and when swallowing medications. The resident's Minimum Data Set (MDS) documented symptoms of a swallowing disorder, and the comprehensive care plan included monitoring for dysphagia but did not specify interventions for responding to symptoms. A provider order for ST evaluation and treatment was obtained and signed, but there was no documentation of ST services being provided after the resident's last discharge from ST in early 2024. Observations revealed the resident continued to experience coughing and choking episodes during meals and after taking medications. Staff interviews confirmed awareness of the resident's symptoms and that the facility had not had an ST on staff since December 2024, with some residents being sent offsite for therapy. The Director of Nursing confirmed that the resident had not received ST since 2024, despite the active order and ongoing symptoms.