Failure to Develop and Implement Communication Care Plan for Non-English Speaking Resident
Penalty
Summary
A Spanish-speaking resident with bilateral leg amputations was admitted to the facility and was her own responsible party. Despite her language needs being documented in the medical record, there was no comprehensive communication care plan in place to guide staff on how to effectively communicate with her. The electronic medical record did not contain a care plan addressing her communication needs, and staff documentation indicated that the resident was unable to describe incidents, such as a fall, due to the language barrier. There was no evidence that translation services or Spanish-speaking staff were consistently utilized to facilitate communication with the resident. Medical provider documentation acknowledged the resident's exclusive use of Spanish and noted challenges in assessing her pain and obtaining her input during evaluations. The provider was not Spanish-speaking, and there was no indication that translation services were used during medical assessments. Interviews with facility leadership confirmed that, prior to a specific date, no communication care plan existed for the resident, and it was unclear if available Spanish-speaking staff had direct contact with her.