Failure to Develop Individualized Communication Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop an individualized and comprehensive communication care plan for a resident with a language barrier. The resident, who was readmitted with chronic kidney disease, Type 2 diabetes mellitus, and essential hypertension, was documented as having severely impaired cognition and a preferred language of Tagalog. The resident did not have the capacity to make medical decisions. Despite these needs, a review of the medical record revealed that no care plan was created to address the resident's language needs. Additionally, during observation, there was no communication board available at the resident's bedside, and staff interviews confirmed the absence of appropriate communication tools. Staff members, including CNAs and the Infection Preventionist, stated that the resident only spoke Tagalog and did not understand English. One CNA recalled that a communication board with pictures had previously been available but was no longer present, and there was uncertainty about its replacement. Staff also reported difficulty communicating with the resident and the need to seek a translator. The facility's policy required comprehensive care plans to be developed within seven days of assessment, but this was not done for the resident's communication needs.