Failure to Notify Physician of Swallow Evaluation Results
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician of the results of a swallowing evaluation. A complaint was received by the Office of Health Care Quality alleging that staff did not notify the physician regarding the results of a swallowing test. Review of the closed clinical record for Resident #1 showed the resident was admitted with severe calorie malnutrition, pharyngeal dysphagia, dementia, and malignant neoplasm of the prostate, and had significant cognitive impairment with a BIMS score of 3/15. During admission, the facility SLP spoke with the resident’s responsible party, who reported that the resident had failed a swallowing test in the hospital but wanted another swallowing test to attempt a diet upgrade. The SLP obtained physician orders and scheduled a FEES exam to be completed at the facility. On the scheduled date, the FEES procedure was performed and the results were available to staff the same day. The FEES report recommended a soft and bite-sized/mechanical soft chopped diet with thin liquids, along with compensatory strategies such as sitting upright, no straws, single sips, small bites, and a slow rate of intake, and suggested consideration of a PROVALE cup if single sips could not be completed independently. Despite the availability of these results and recommendations, there were no nursing progress notes in the resident’s chart indicating that the physician had been informed of the FEES results. In an interview, the DON confirmed that the record lacked documentation that the resident’s physician was made aware of the swallowing evaluation findings.
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