Failure to Provide Rehabilitative Services for Eating Skills Restoration
Penalty
Summary
The facility failed to provide appropriate rehabilitative services to restore eating skills for a resident who had recently experienced a stroke and was readmitted to the facility with new orders for NPO status and tube feedings due to dysphagia. Prior to the stroke, the resident was cognitively intact, able to make needs known, and required only set-up assistance with eating. Upon readmission, the resident's cognition was initially impaired, but improved after the first week, making the resident a candidate for speech/language pathology (SLP) services to address swallowing and eating skills. However, the facility did not provide SLP services because there had been no speech therapist on staff since October 2024. Medical record review showed that the resident had a history of cerebral infarction with left hemiplegia, aphasia, and other significant comorbidities. Hospital documentation recommended ongoing SLP evaluation and treatment, but there was no evidence of such services being provided after the resident's return to the facility. The Director of Rehab confirmed that although the resident could have benefited from SLP services after cognitive improvement, these services were not offered due to the absence of a speech therapist. This resulted in a lack of care and services aimed at restoring the resident's eating skills.