Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
A resident who primarily spoke Mandarin and was admitted with multiple diagnoses, including osteoporosis and chronic pulmonary edema, was identified as having a language barrier. The resident's care plan, which addressed the language barrier, specified that staff should provide and utilize communication boards in the resident's preferred language to facilitate communication. The resident was assessed as having the capacity to understand and make decisions and required partial or moderate assistance with activities of daily living such as toileting hygiene and bathing. Despite these documented needs and interventions, observations and interviews revealed that a communication board was not present or accessible at the resident's bedside. Both the treatment nurse and the Director of Nursing confirmed that a communication board should have been available to support the resident's ability to communicate needs, especially in the absence of a translator, family member, or bilingual staff. The facility's policy also required identification and accommodation of communication deficits, but this intervention was not implemented for the resident.
Plan Of Correction
F-tag 676 Activities Daily Living (ADLs) Maintain Abilities Immediate corrective action: On 04/28/25, Social Services Director provided Resident 24 a Mandarin communication board at bedside. From 05/02/25 to 05/10/25, DON provided in-services/retraining and re-education to Social Services regarding policy on accommodation of needs to ensure communication boards are provided to residents with language barriers. Identification of others at risk: On 05/02/25, Social Services Director and Social Services Assistant conducted rounds on residents with language barriers to ensure communication boards are provided at bedside. No other residents were identified with the same deficient practice. Process to prevent recurrences: In-services by the DON were provided on 05/02/25 and 05/20/25 to nursing staff (CNA, LVN, RN) and Social Services to reinforce the policy of accommodation of needs. Social Services Director and Social Services Assistant will screen new admits to ensure if a resident speaks a language other than English, a communication board/book will be given. Monitoring process: The Social Services Director will conduct weekly random checks for 3 months to ensure communication boards are provided and kept at the bedside of residents with language barriers. The Administrator will spot check monthly reviews of findings. Any deficient practices identified will be discussed during the monthly CQI/QA meeting for further recommendations. Repeated identification of others at risk: On 05/02/25, Social Services Director and Social Services Assistant conducted rounds on residents with language barriers to ensure communication boards are provided at bedside. No other residents were identified with the same deficient practice. Process to prevent recurrences (continued): In-services by the DON were provided on 05/02/25 and 05/20/25 to nursing staff (CNA, LVN, RN) and Social Services to reinforce the policy of accommodation of needs. Social Services Director and Social Services Assistant will screen new admits to ensure if a resident speaks a language other than English, a communication board/book will be given. Monitoring process (continued): The Social Services Director will conduct weekly random checks for 3 months to ensure communication boards are provided and kept at the bedside of residents with language barriers. The Administrator will spot check monthly reviews of findings. Any deficient practices identified will be discussed during the monthly CQI/QA meeting for further recommendations. Completed date: 5/20/2025