Failure to Provide Communication Device for Resident with Aphasia
Penalty
Summary
The facility failed to maintain a resident's ability to communicate as outlined in their care plan. The resident, who had diagnoses including aphasia and adult failure to thrive, was admitted with the ability to communicate needs and was identified as hard of hearing. The care plan specified the use of a dry erase board to facilitate communication. However, during multiple observations, the resident was found in bed without a whiteboard present, despite signage indicating its use for communication. Staff interviews confirmed that the whiteboard, previously used to communicate with the resident, had been missing for some time and had not been replaced. Further interviews revealed that staff were aware of the care plan intervention but did not report the missing communication device, resulting in the resident being unable to effectively communicate with facility staff. The resident confirmed that staff did not use writing to communicate with them. The Director of Nursing Services acknowledged that communication devices should be kept at the bedside and missing devices should be reported, but this protocol was not followed in this instance.