Failure to Provide Communication Supports and Ostomy Supplies
Penalty
Summary
The facility failed to provide appropriate means for a resident with communication barriers to effectively communicate with staff. One resident, who was Spanish-speaking and had limited use of his right arm and hand due to multiple medical conditions including stroke and muscle weakness, was unable to access a communication board that was placed on the right side of his bed, out of his reach due to raised bed rails. The resident's care plan identified a potential communication problem and included interventions such as providing a translator and evaluating alternate communication methods, but these were not effectively implemented. Interviews revealed that while some staff and therapists spoke Spanish, there was no assurance that communication needs were met when Spanish-speaking staff were not present, and the resident expressed frustration over the removal of a sign created by his family that helped communicate his needs. Another deficiency involved the facility's failure to ensure a resident with a colostomy had timely and consistent access to necessary ostomy supplies to independently maintain her ostomy care. The resident, who was cognitively intact and managed her own colostomy, reported frequent delays in receiving replacement ostomy bags, sometimes resorting to using zip-loc bags overnight when supplies were not provided. She also reported skin irritation due to these delays. Interviews with staff revealed confusion regarding responsibility for providing colostomy care and supplies, with nurses and CNAs each indicating the other was responsible. The central supply coordinator confirmed that supplies were available and accessible to nursing staff, indicating the issue was not due to a supply shortage. Both deficiencies were substantiated through interviews, observations, and record reviews, demonstrating that the facility did not ensure residents maintained their ability to perform activities of daily living, such as communication and ostomy care, due to failures in providing necessary supports and supplies as outlined in their care plans.