Failure to Provide Timely and Accurate Rehabilitative Services and Care Plan Updates
Penalty
Summary
The facility failed to provide patient-centered rehabilitative services for a resident who had experienced multiple hospitalizations and was readmitted to the facility. Despite the facility's policy requiring interdisciplinary screening for all therapy disciplines upon admission or readmission, speech therapy (ST) was not initiated or screened during the resident's stay or after changes in condition following hospitalization. The Director of Rehabilitation Services indicated that ST was only identified if requested by nursing or other therapies, and noted that speech therapy staff had not been available for some time. Although occupational therapy (OT) and physical therapy (PT) completed interdisciplinary screens, no ST recommendations were made, and the required screening process was not followed as per facility policy. A speech therapy evaluation was eventually completed, resulting in a recommendation for the resident to remain NPO (nothing by mouth), with specific instructions for pleasure feeding and safe swallowing practices. However, the resident's care plan was not updated to reflect the current NPO order and continued to document oral intake with pureed foods, which conflicted with the most recent recommendations. The Director of Nursing confirmed the care plan was inaccurate and that the resident had not consumed any food. No instrumental swallowing studies were completed, and the lack of timely and accurate therapy screening and care plan updates led to the deficiency.