Failure to Provide Ordered Speech Therapy and Swallow Evaluation
Penalty
Summary
The facility failed to provide a required Speech Therapy (ST) and swallow evaluation for a resident with a history of hemiplegia, hemiparesis following cerebral infarction, dysphagia, dementia, and depression. The resident was admitted and readmitted with these diagnoses, and care plans were in place to monitor for signs and symptoms of dysphagia, including pocketing, choking, and difficulty swallowing. On a specific date, the resident was observed to be pocketing food, and the family reported swallowing difficulties. The physician was notified and ordered a speech and swallow evaluation, as well as a calorie count. Despite the physician's order for an ST and swallow evaluation, the service was not provided because the facility did not have an ST available at the time. 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 the lack of available staff. There was no documentation that the physician was notified about the inability to provide the ordered evaluation. Progress notes continued to document the resident's ongoing difficulty with swallowing and pocketing food in the days following the order. The resident's condition declined, with continued reports of difficulty swallowing, pocketing food, and eventually being unable to eat, coughing, and requiring transfer to a general acute care hospital. Staff interviews confirmed that the resident choked during feeding attempts and that the lack of ST services was known to both the Director of Rehab and the DON, but no alternative arrangements or notifications to the physician were documented. Facility policy required provision of rehabilitative services as indicated and notification of the physician and family when significant changes in condition or treatment occurred, but these were not followed in this case.