Failure to Support Resident Communication Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not supporting the resident's choice to have a sign displaying personal preferences, dislikes, and family contact information posted in the resident's room. The resident, who was Spanish-speaking and assessed as cognitively intact with a BIMS score of 13, relied on the sign for communication due to a language barrier and limited English proficiency. The sign, created by the resident's family, was observed over the resident's bed but was later removed by an unknown individual. The resident and his spouse, both with limited English skills, expressed distress over the removal, stating that the sign was essential for communicating needs to staff. Interviews with facility staff, including the Social Services Director, DON, and Administrator, revealed that none of them knew who removed the sign or why it was taken down. The resident reported that the sign was not removed by direct care staff, but could not identify the person responsible. The care plan for the resident included interventions to address communication barriers, such as providing a translator and evaluating alternative communication methods, but did not address the removal of the sign. The lack of communication and failure to support the resident's expressed preference led to the deficiency.