Failure to Accurately Document and Assess Dysphagia Diagnosis and Care Needs
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status, specifically regarding a diagnosis of dysphagia and the need for a modified diet and crushed medications. The resident, an older adult male with multiple diagnoses including kidney failure, dementia, Parkinson's disease, stroke, and a history of stomach cancer, did not have dysphagia documented on his face sheet, Minimum Data Set (MDS), or care plan, despite evidence from a speech therapy evaluation indicating the presence of dysphagia and the need for swallowing precautions, a modified diet, and crushed medications. Review of the resident's records showed that the care plan and MDS did not include a diagnosis of dysphagia or interventions related to swallowing difficulties or medication administration. The speech therapy evaluation documented specific swallowing impairments and recommended interventions, but these were not reflected in the resident's official diagnoses or care planning documents. Interviews with facility staff, including the speech pathologist and MDS nurse, confirmed that the resident required these interventions and that the diagnosis should have been included in the resident's records and care plan. The MDS nurse acknowledged that the omission of the dysphagia diagnosis and related care plan interventions was an error and that the resident's assessments and care plan were inaccurate at the time of the survey. The facility's policy on certifying the accuracy of resident assessments did not specifically address the accuracy of assessments, and the responsible staff confirmed that the resident's records were not updated to reflect the dysphagia diagnosis and required interventions until after the surveyor identified the discrepancy.