Failure to Accommodate Resident's Physical and Communication Needs
Penalty
Summary
The facility failed to provide a comprehensive, resident-centered treatment plan to accommodate the physical and communication needs of a resident with multiple complex diagnoses, including encephalopathy, type 2 diabetes, aphasia, hemiplegia, and cognitive impairment. Occupational therapy notes indicated ongoing issues with wheelchair fit and support, with the resident expressing fear of falling and discomfort due to improper leg support. Staff interviews revealed uncertainty about the appropriateness of the wheelchair, lack of awareness of the resident's concerns, and inconsistent use of necessary equipment such as a properly sized footbox. Observations confirmed the resident's legs were inadequately supported, and staff resorted to using pillows as a makeshift solution. In addition to physical needs, the resident's communication challenges were not adequately addressed. Speech therapy discharge recommendations included specific strategies and training for staff to facilitate communication, such as using visual aids and concrete directions. However, interviews with staff indicated a lack of awareness or training on these techniques, and the resident reported ongoing frustration with her ability to communicate. The care plan included interventions for impaired communication, but the resident was not provided with communication tools until after surveyor intervention. Throughout the period reviewed, there was a lack of coordination and follow-through among therapy, nursing, and direct care staff regarding both the resident's physical and communication needs. Staff were unclear about the equipment provided, the training received, and the interventions required to support the resident's well-being and dignity. These deficiencies resulted in the resident not achieving or maintaining her highest level of well-being, as evidenced by her fear, discomfort, and frustration.