Failure to Implement and Document Diet Changes After Swallow Study and SLP Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to act on speech therapy and swallow study recommendations for a resident with dysphagia and multiple neurologic and cognitive impairments. The resident had diagnoses including cerebral infarction, late-onset Alzheimer’s disease, generalized muscle weakness, dementia, and dysphagia. The admission MDS and associated CAAs documented that the resident required partial to moderate assistance with eating and other ADLs, had poor but improving appetite, and was on a CCHO/LCS diet with regular texture and consistency. The care plan identified risks for weight loss, swallowing and chewing problems, and directed staff to monitor intake, assure correct diet consistency for safe swallowing, and obtain speech therapy if chewing or swallowing problems were observed. Speech therapy notes documented that the resident had an episode of significant coughing and difficulty swallowing meat, after which nursing reportedly downgraded the diet to mechanical soft. On the following day, a FEES study was completed, which recommended a minced and moist mechanical soft diet with thin liquids, medications whole or cut in puree, and specific swallow strategies including maintaining upright positioning during and after meals and using a double swallow with every bite and drink. A subsequent speech therapy note recorded that the resident’s diet was mechanical soft with thin liquids and pills crushed in puree, and that the resident required total supervision at meals for safety. However, the EMR showed only a physician’s order for a CCHO/LCS diet with regular texture and consistency from admission through early February, with no documented diet changes or new diet orders reflecting the FEES recommendations. The swallow study report was uploaded into the resident’s EMR under the Misc tab by a licensed nurse, but the record lacked evidence that the provider was formally notified of the results or that any physician response was documented. Interviews with administrative and nursing staff revealed uncertainty about what happened with the swallow study and speech therapy recommendations, and staff described a process in which results were scanned into the EMR but might not generate alerts for review. The nurse who uploaded the swallow study stated she contacted the provider by phone, was told to continue the regular diet without changes, and did not document this contact or the provider’s response in a progress note. She also indicated she was unsure whether the provider had seen the speech therapy notes or recommendations. No relevant facility policy regarding handling orders and recommendations was provided upon request, and the EMR contained no evidence of diet order changes or documented physician rationale related to the swallow study and speech therapy recommendations during the resident’s stay.
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