Failure to Communicate ST Feeding Recommendations and Obtain Timely Physician Orders
Penalty
Summary
The facility failed to provide necessary care and services in accordance with standards of practice for one resident by not relaying a speech therapist’s recommendation for feeding assistance to the physician and not obtaining corresponding physician orders. The resident had a history of hyperlipidemia, hemiplegia and hemiparesis following a stroke affecting the right dominant side, and oropharyngeal aphagia. An MDS dated 12/10/2025 documented cognitive impairment and a need for staff supervision with eating, as well as partial/moderate assistance for oral and personal hygiene. A speech-language pathology evaluation and plan of treatment dated 11/16/2025 indicated the resident was on three meals with assistance of feeding to enhance safe swallow. However, there was no documented evidence that this recommendation was communicated to the physician or that an order for this assistance was obtained between 11/16/2025 and 12/21/2025. During this same period, from 11/17/2025 to 12/19/2025, the resident was observed and assessed to be able to feed himself without 1:1 assistance, yet the facility did not relay this change in status to the physician or obtain an order for a new ST evaluation to reassess the resident’s feeding needs. Physician orders only reflected a 1:1 feeding requirement to prevent aspiration beginning on 12/22/2025 at 10:56 PM, with no such orders in place from 11/16/2025 to 12/21/2025. The resident’s care plan for risk of aspiration, initiated 11/18/2024 and revised 12/18/2025, directed staff to monitor for signs and symptoms of aspiration, provide prompt intervention, and inform the physician, and a separate care plan for swallowing problems was initiated on 12/4/2025. Despite these care plan directives and the ST evaluation, the facility did not ensure physician notification and appropriate orders regarding feeding assistance and ST reevaluation during the identified timeframe.
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