Failure to Implement and Document Speech Therapy Diet Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to follow and document recommended dietary changes according to professional standards of practice and the facility’s Diet Changes policy for one resident with dysphagia and dementia. The resident was admitted with diagnoses including dysphagia and dementia, and an MDS dated 11/26/2025 showed a BIMS score of 12, indicating moderate cognitive impairment. The resident’s Order Summary Report for diet listed a regular diet with minced and moist texture and mildly thick liquids, while a Speech Therapy Evaluation and Plan of Treatment dated 12/6/26 recommended puree solids and nectar thick liquids, creating a discrepancy between the active diet order and the speech therapy recommendations. Interviews with nursing staff and the DON confirmed that the facility’s established process required nursing staff to assess swallowing concerns, notify the physician to request a speech therapy evaluation, and, once recommendations were received, notify the physician of the new recommendations, update the diet order in the medical record, and notify dietary staff. LVN 1 and LVN 2 both described this process, stating that after speech therapy completed an evaluation and provided new recommendations, nursing staff were responsible for notifying the physician, changing the diet order, and communicating the change to dietary. The DON similarly stated that once speech therapy recommendations were received, the licensed nurse should notify the physician to obtain new diet orders, change the diet order in the record, and notify dietary immediately. The speech therapist confirmed that the new diet recommendations for puree solids and nectar thick liquids differed from the previous diet order and stated that the new diet should have been changed by facility staff on the day the evaluation was completed, with nursing staff following up with the physician and ensuring the diet was changed in the medical record. Review of the facility’s Diet Changes policy indicated that Nursing Services must notify the Food & Nutrition Department in writing of any diet change. A professional reference from the American Nurses Association on Principles for Nursing Documentation emphasized that documentation must be clear, accurate, complete, and properly authenticated. Despite these standards and policies, the resident’s diet order in the medical record was not updated to reflect the speech therapy recommendations, and the physician was not notified of the recommended diet change.
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