HospitalInspections.org

Based on medical record review, review of facility investigation, and interview, the facility failed to provide a speech therapy evaluation as ordered by a physician for one patient (#4) of five sampled patients.

The findings included:

Patient #4 was admitted to the facility on April 4, 2012, with diagnoses including Hypertension.

Medical record review of the History and Physical dated April 4, 2012, revealed, "...Speech is appropriate but somewhat labored and thickened sound...no focal neurologic deficits noted..."

Medical record review of a Neurology Consultation dated April 5, 2012, revealed, "...Impression...Acute ischemic subcortical stroke...mild dysarthria...Further management options according to clinical improvement and study results."

Medical record review of a physician's order dated April 5, 2012, revealed, "...speech & swallow eval (CVA) (evaluation - cerebrovascular accident)..."

Medical record review of a nurse's note dated April 6, 2012, at 3:35 p.m., revealed, "MD (medical doctor) notified...speech therapy wont (won't) see pt (patient) til (until) Mon (Monday). Outpt (Outpatient) cannot see til Mon (Monday) either...md (Medical Doctor) upset d/t (due to) (doctor) personally had talked to (speech therapist) and was told pt would be seen on 4/5/12..."

Medical record review revealed no documentation regarding an evaluation by speech therapy.

Medical record review revealed the patient was discharged to home on April 7, 2012.

Review of a facility investigation authored by the Director of Rehabilitation and dated June 6, 2012, revealed the physician's order was entered into the facility's computer system on April 5, 2012, at 7:45 p.m., and included "Only two orders were received April 6th (Patient #4's) was not one of those..."

Interview with the Risk Manager on June 6, 2012, at 12:15 p.m., in a conference room, confirmed the facility had failed to provide a speech therapy evaluation for Patient #4 as ordered by a physician on April 5, 2012.