Missed Speech Therapy Evaluation Order
Penalty
Summary
A speech therapy evaluation ordered by a physician for one resident with Myasthenia Gravis and Parkinson's Disease was not completed as required. The physician's order for the evaluation was placed, but 43 days later, there was no documentation in the resident's record indicating that the evaluation had been performed. The speech therapist confirmed that the evaluation was missed, and the Director of Rehabilitation acknowledged that such evaluations should be completed within approximately 48 hours of the order. Nursing staff interviewed stated that they were responsible for verifying that speech therapy consults were completed to ensure residents received the correct diet. The facility's policy indicated that specialized rehabilitative services, including speech pathology, are to be provided upon written physician order. Despite these policies and staff responsibilities, the required speech therapy evaluation was not conducted for the resident.