Failure to Provide Communication Board for Nonverbal Resident
Penalty
Summary
Facility staff failed to provide a communication board for a resident who was unable to speak, as required by the resident's care plan. The care plan, dated 10/14/2024, identified the resident's communication problem and included interventions such as ensuring the availability and functioning of adaptive communication equipment, including a message board and alternative communication tools. During an observation, the resident was found sitting on the bed, unable to verbally communicate but able to nod and shake her head. When asked, the Certified Nurse Assistant present was unable to locate the communication board for the resident. A review of the facility's policy on accommodation of needs indicated that residents' individual needs and preferences, including access to assistive and adaptive devices, should be accommodated to the extent possible. Despite this policy and the care plan's directives, the communication board was not available for the resident's use, resulting in a failure to ensure continued communication for the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 3 was immediately offered an alternative method of communication on July 9, 2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On July 9th, 2025, the Director of Nursing (DON) / designee ensured that all non-verbal residents were provided with appropriate means of communication. This measure was implemented to prevent any lapses in communication between the facility and the affected residents. No additional findings were noted.