Failure to Provide Effective Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure the right to a dignified existence, self-determination, and effective communication for a resident with limited English proficiency. The resident, a Spanish-speaking male with diagnoses including diabetes mellitus, diabetic arthropathy, and a cognitive communication deficit, was unable to communicate effectively with staff who did not speak Spanish. The care plan identified the resident's communication needs and included interventions such as the use of visual cues, gestures, flash cards, and a communication board, as well as contacting family or friends for assistance. However, observations revealed that these interventions were not effectively implemented, as the communication board was not accessible or useful to the resident, and staff frequently relied on ad hoc methods such as sign language or seeking out Spanish-speaking staff when available. Multiple staff interviews confirmed that most staff, including those on evening and night shifts, did not speak Spanish and found the communication board ineffective. Staff reported difficulty in assessing the resident's needs, including pain levels, and often depended on non-verbal cues or attempted to find a Spanish-speaking colleague, which was not always possible. The Director of Rehabilitation, who was a Spanish speaker, acknowledged concerns about the lack of Spanish-speaking staff during certain shifts and the resulting communication barriers. The Director of Nursing and Administrator also recognized the importance of communication but indicated that the primary tools available were the communication board and the ability to call a Spanish-speaking staff member by phone, which was not consistently utilized. Review of facility policy confirmed the right of residents to communication and access to services, but no specific policy for non-English speaking residents was provided when requested. Observations and interviews demonstrated that the resident was unable to reliably communicate his needs or understand staff instructions, and the interventions outlined in the care plan were not effectively supporting his communication needs.