Failure to Coordinate Communication Services for Non-Verbal Resident
Penalty
Summary
The facility failed to coordinate appropriate services to address the communication needs of a resident with a persistent vegetative state and traumatic brain injury. Upon admission, the resident's ability to understand others was not assessed, and although a physician order was made for physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) at the family's request, there was no evidence that these referrals were promptly initiated. During a care conference, the family specifically requested referrals for OT, PT, SLP, and a neurologist, but staff were unclear about whether the SLP referral had been made. The resident's care plan was updated to reflect non-verbal communication needs, but staff interviews revealed uncertainty about how SLP could assist and a lack of timely follow-through on the requested services. Observations and interviews indicated that the resident attempted to communicate through non-verbal means such as eye movements, grunting, and swatting at staff. Staff members, including a CNA and the Activities Director, described the resident's responses to stimuli and attempts to make needs known, but there was no evidence of assessment for improved communication technology as requested by the family. The Regional Director of Quality Assurance confirmed that referrals for communication services were expected to be initiated as soon as requested, but acknowledged that there was a delay in providing these services for the resident.