Failure to Provide Accessible Communication Board for Non-English Speaking Resident
Penalty
Summary
Staff failed to ensure reasonable accommodation of a resident's communication needs by not making the resident's pictogram communication board accessible. The resident, who only speaks Korean and has diagnoses including schizoaffective disorder, major depressive disorder, and failure to thrive, relies on the pictogram as her primary means of communication due to cognitive deficits and fluctuating capacity to understand and make decisions. During observation and interviews, it was found that the pictogram was kept inside the bedside table drawer, out of the resident's reach, contrary to the care plan intervention which specified that the communication board should be provided if applicable. Certified Nurse Assistant (CNA) and Licensed Vocational Nurse (LVN) interviews confirmed that the pictogram was not accessible and that staff rely on it to understand the resident's needs. The facility's Director of Nursing (DON) and policy documents also indicated that communication devices must always be kept within reach to allow residents to express their needs, preferences, and concerns. The failure to keep the pictogram accessible was a direct violation of the facility's policy and the resident's care plan, impeding the resident's ability to communicate effectively.