Failure to Use Communication Board for Non-English Speaking Resident
Penalty
Summary
Staff failed to use a communication board as required by the care plan for a resident whose primary language is Spanish and who was dependent on staff for all activities of daily living. The resident had a history of cerebrovascular accident, tracheostomy with ventilator dependence, and fluctuating capacity to understand and make decisions. During an observation, the resident was seen grimacing and expressing pain, but the nurse communicated only in English and did not use the communication board, resulting in the resident not understanding the nurse and her pain needs not being effectively addressed. Interviews with staff confirmed that the communication board was not used during the pain assessment, despite it being part of the resident's care plan and facility policy. The nurse supervisor and DON acknowledged that staff are trained to use the communication board and that failure to do so can result in unmet resident needs. Facility policy also required the use of communication aids for residents assessed to need them.