Failure to Address Resident's Communication Needs in Care Plan
Penalty
Summary
The facility failed to develop, implement, and revise a person-centered, comprehensive care plan to address the communication needs of a resident who was dependent on staff for all activities of daily living and had significant language and speech barriers. The resident, who had a history of stroke with residual speech and language deficits, impaired mobility, and other chronic conditions, was only able to understand Spanish and could not speak. Despite this, the care plan and CNA Kardex did not reflect the resident's preferred language or provide individualized communication strategies to address the language barrier. Staff interviews revealed that care was often provided in English, and there were no formal assignments of Spanish-speaking staff to assist the resident. A sign in the resident's room indicated her language needs, but this information was not incorporated into her official care plan. Family members expressed concerns to facility leadership about the resident's inability to understand staff, which led to the resident becoming frightened and withdrawn. The facility's own assessment acknowledged the presence of Hispanic residents and the need for culturally and linguistically appropriate care, but this was not translated into practice for this resident. Both the unit manager and MDS coordinator confirmed that the resident's language preference should have been included in the care plan, but it was not, and there was no evidence that this issue was discussed or addressed in care plan meetings.