Failure to Develop and Implement Communication Care Plan for Nonverbal Resident
Penalty
Summary
The facility failed to implement a person-centered care plan addressing communication needs for a resident with severe cognitive impairment and nonverbal status. The resident, admitted with diagnoses including hemiplegia, aphasia, and severe cognitive impairment (BIMS score 0/15), was observed to only respond to yes or no questions by shaking his head. Despite these significant communication barriers, review of the resident's care plan revealed no individualized plan for communication, even though the facility's policy requires comprehensive care plans to address all identified needs. Interviews with staff, including a CNA, speech therapist, MDS coordinator, and DON, confirmed that the resident was nonverbal and communicated through gestures or head movements. Staff relied on the Kardex for information about the resident's communication methods, but acknowledged the absence of a formal communication care plan. The speech therapist specifically stated that the resident should have a care plan for communication, and the DON expected one to be in place, in accordance with facility policy.