Failure to Implement Physician-Ordered Speech Services Due to Order Entry Error
Penalty
Summary
The facility failed to ensure that professional standards of care were followed regarding the implementation of physician-ordered speech services for a resident. The resident was admitted with multiple diagnoses, including muscle weakness and a neurological disorder, and was assessed as cognitively intact. A physician order was entered for a one-time speech evaluation due to increased weakness in the resident's voice. However, the order was incorrectly entered with a one-day stop date, causing it to be automatically marked as completed in the system, even though the evaluation was never performed. The speech therapist did not receive notification of the order and therefore did not conduct the evaluation. The Director of Nursing confirmed that the speech evaluation was not completed and could not be located. The resident reported never receiving speech therapy, and the speech therapist stated he was unaware of any new orders for the resident. Facility documentation and interviews revealed that the failure to properly enter and communicate the physician's order resulted in the resident not receiving the required speech evaluation as ordered.