Failure to Implement Comprehensive Care Plan for Resident with Language Barrier
Penalty
Summary
The facility failed to follow a comprehensive, person-centered care plan for a resident with limited English proficiency (LEP). According to the facility's Care Plan Policy and Language Access Policy, each resident should have a care plan that addresses their individual needs, including communication barriers, and provides a written summary in a language the resident or their representative can understand. The care plan for the resident in question identified a risk for communication problems due to a language barrier and included interventions such as using gestures, family support, and pen and paper. However, staff interviews revealed that a communication device, which could have supported the resident's needs, was not included in the care plan, and the MDS staff member was unaware of its necessity. Additionally, the facility's policy required staff to identify language needs upon admission, document language preferences, and use qualified interpretation services when necessary. Despite these requirements, there was no documentation that the Language Line service was used or that the resident's language needs were fully addressed. The DON confirmed that if an intervention is indicated on the care plan, it is expected to be followed, but in this case, the care plan was not comprehensive enough to meet the resident's communication needs, potentially leaving those needs unmet.