Failure to Notify Physician of Inability to Provide Ordered Speech Therapy and Resident's Ongoing Swallowing Difficulties
Penalty
Summary
The facility failed to notify the attending physician when a resident did not receive a physician-ordered speech therapy (ST) and swallow evaluation due to the absence of a speech-language pathologist (SLP) in the building. The resident, who had a history of hemiplegia, hemiparesis, dysphagia, dementia, and depression, was admitted with significant swallowing difficulties, including pocketing food and choking. Despite a physician's order for an ST and swallow evaluation, the service was not provided because the facility had no ST available after the therapist resigned. The Director of Rehab confirmed that the last day an ST was present was prior to the order, and the resident was discharged from ST services due to this lack of availability. Progress notes and care plans indicated ongoing monitoring of the resident's swallowing difficulties, with repeated documentation of continued pocketing and difficulty swallowing over several days. However, there was no documentation that the physician was notified about the facility's inability to provide the ordered ST evaluation or about the resident's persistent symptoms. The Director of Nursing acknowledged during interviews that there was no evidence of physician notification regarding the lack of ST services or the resident's ongoing swallowing issues. The resident's condition continued to decline, culminating in an acute change in condition where the resident was unable to eat, was coughing, and continued to pocket food, ultimately requiring transfer to a general acute care hospital. Facility policy required notification of the physician and family when changes in condition or inability to provide ordered services occurred, but this was not done in this case, resulting in a delay of care for the resident.