Failure to Accurately Assess Language Needs
Penalty
Summary
The facility failed to ensure a comprehensive assessment was completed accurately for a resident regarding language and communication needs. The resident, who was admitted with diagnoses including traumatic subdural hemorrhage, cerebral infarction, and dementia, was on comfort care. A Brief Interview for Mental Status (BIMS) assessment indicated moderate cognitive impairment and noted the resident's preferred language as Vietnamese. However, the Admission Assessment MDS did not reflect that the resident spoke a different language, and no care plan for communication was found in the clinical record. Observations and clinical notes further highlighted the communication barrier, as the resident was unable to communicate in English and required interpreter services. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the resident primarily communicated in Vietnamese, and this should have been documented in the Care Area Assessment. The deficiency was identified under 28 Pa Code 211.12 (d)(1) Nursing services.
Plan Of Correction
This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. Facility is unable to retroactively correct this deficiency. An audit was completed to identify all residents that speak a different language who have been admitted to the facility in the last month, to ensure that the Care Area Assessment reflects that those residents speak a different language. Education will be provided to the RNAC to ensure that all residents that speak a different language have it reflected in the Care Area Assessment. DON/Designee will audit all the Admissions Assessment MDS for all new admissions that speak a different language to make sure that the Care Area Assessment reflects that they speak a different language. Audit will be done weekly x4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed.