Failure to Accurately Document Resident Communication Needs in Facility Assessment
Penalty
Summary
The facility failed to accurately document all languages used by residents in its facility-wide assessment, specifically omitting sign language as a primary communication method for one resident. The facility's policy requires the assessment to address the care needs of the resident population, including pertinent facts such as languages used. However, the most recent facility assessment listed only English as the language used by all residents, despite evidence to the contrary. A resident with diagnoses including developmental disorder of speech and language, nonspeaking deafness, and severe cognitive impairment was observed and reported to use sign language and personalized hand gestures as her primary means of communication. Multiple staff members, including an LPN and a CNA, confirmed that sign language and gestures were used to communicate with the resident, as she was unable to use written communication tools like a dry erase board. Observations further confirmed the use of sign language between the resident and staff, and the DON and Administrator acknowledged that sign language was the resident's primary communication method, which was not reflected in the facility assessment.