Failure to Provide Required Speech Therapy Services for Residents with Swallowing and Dietary Needs
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically speech therapy, for two residents who required such interventions. For one resident, the diet was downgraded from regular texture to puree texture due to ongoing weight loss, but there was no speech therapy consult prior to this significant change. The registered dietician confirmed that such a downgrade should not occur without a speech consult, and the DON acknowledged that staff had not been following the necessary steps for diet changes involving texture modifications. Another resident, who had a history of recurrent aspiration pneumonia and multiple hospitalizations for related complications, was placed on an NPO (nothing by mouth) diet. Despite the resident's reports of not receiving speech therapy for swallowing difficulties and expressing a desire to eat, there was no recent SLP evaluation or swallowing study. The last SLP evaluation was over a year prior, and the resident had not received swallowing therapy or exercises, nor any recent diagnostic tests to reassess swallowing ability. The facility's process for speech therapy referrals relied on telehealth evaluations and outpatient services, but there was no evidence of timely or adequate reassessment for this resident despite significant changes in condition and repeated hospitalizations. Interviews with facility staff revealed gaps in the interdisciplinary team (IDT) process, with daily meetings occurring but no formal IDT meetings to discuss significant changes or therapy needs. The facility's screening policy required therapy services for new admissions and readmissions, but in these cases, the necessary speech therapy consults and evaluations were not completed as required, leading to a failure to provide appropriate specialized rehabilitative services.