Failure to Assess Effectiveness of Communication Board for Severely Impaired Resident
Penalty
Summary
The facility failed to assess the effectiveness of a communication board used for a resident with severe cognitive impairment and hearing loss. The resident, who was admitted with unspecified dementia and hearing loss, was unable to verbally communicate and did not respond to verbal greetings, though she smiled. Staff, including the Infection Preventionist and Certified Nursing Assistants, attempted to use a communication board with English-language symbols and pictures to communicate with the resident. However, multiple staff members observed that the resident did not appear to understand the board or its symbols, and her responses to the board were not meaningful or indicative of her needs. Despite this, staff continued to use the communication board as a primary communication tool. The resident's records indicated she was not capable of understanding her rights or participating in her treatment plan, and her BIMS score showed she was unable to complete the cognitive assessment. Staff were unsure of the resident's primary language, though it was noted her family spoke Mandarin, and no staff spoke Mandarin. The DON confirmed that the resident was severely impaired and unable to comprehend the communication board, and that interpretation services had not been used due to her cognitive status. The facility did not evaluate or revise the care plan to address the ineffectiveness of the communication board, resulting in a failure to identify and meet the resident's communication needs.