Failure to Develop Comprehensive Communication Care Plan for Nonverbal Resident
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan for a resident with significant cognitive impairment and nonverbal status following a traumatic brain injury. The resident, who was quadriplegic, had a tracheostomy and a PEG tube, was unable to communicate verbally and relied on nonverbal cues such as blinking, laughing, and tracking with his eyes to interact with staff. Medical records and staff interviews confirmed that the resident used specific blinking patterns to indicate 'yes' or 'no' responses, and also responded with laughter and eye movements. Despite this, the resident's care plan did not include detailed interventions or instructions for staff on how to communicate with him using these established nonverbal methods. The care plan only generally addressed altered communication and cognition, with interventions limited to assessing pain using a specific pain scale. There was no documentation in the care plan about the resident's unique communication methods, such as blinking or tracking with his eyes, nor was there information about his baseline behaviors like laughing or smiling. This omission meant that staff did not have consistent, documented guidance on how to effectively communicate with the resident.