Failure to Document Communication Aid in Care Plan
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered care plan that included documentation of a communication aid for a resident with multiple diagnoses, including ataxia, which impaired verbal communication. The resident was cognitively intact but had difficulty expressing himself verbally, requiring the use of a communication aid consisting of laminated pages with words and letters, as recommended by the speech therapist. The speech therapy discharge summary indicated that the resident's communicative effectiveness improved with the use of trained strategies and aids. Despite these recommendations and the resident's ongoing need for the communication aid, the care plan only addressed general communication strategies such as identifying oneself, making eye contact, and using simple sentences, but did not document the use of the specific communication aid. Staff interviews confirmed that the care plan lacked this critical intervention, and there was no documented evidence that the communication aid was included in the resident's care plan to support his ability to communicate.