Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident with a communication barrier due to language. The resident, admitted with chronic respiratory failure, was assessed as having no memory problems and communicated only in Russian. The care plan specified the use of a communication board to facilitate communication between staff and the resident. However, during multiple observations and interviews, it was found that the communication board was not available in the resident's room, and staff were unable to effectively communicate with the resident without it. Staff, including a licensed nurse and a social worker, confirmed the absence of the communication board and acknowledged the difficulty in communicating with the resident as a result. The Director of Nursing also confirmed that the care plan required the use of a communication board and emphasized its importance for providing appropriate care. A review of facility policy indicated that communication boards should be provided for non-bilingual staff to communicate with residents who have language barriers, but this was not implemented for the resident in question.
Plan Of Correction
The DSD or designee (in conjunction with Social Services) will conduct daily audits of residents requiring communication boards for 2 weeks, then weekly for 1 month, and monthly thereafter to ensure devices are present and properly utilized. The Social Services Director will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee quarterly for 2 quarters or until substantial compliance is achieved and maintained. The QAPI committee will make recommendations for additional interventions or modifications as needed. All corrective action will be completed by 5/26/25.