Failure to Accurately Assess Resident Status Due to Incomplete Observation and Language Barriers
Penalty
Summary
The facility failed to conduct accurate assessments for two residents, resulting in their needs not being properly identified or met. One resident, a female with severe cognitive impairment, left-sided weakness from a stroke, and a history of falls, was observed wandering unsupervised on and off the unit over several days. Despite these observations and the daily use of a wander/elopement alarm, her Minimum Data Set (MDS) quarterly review did not code her as exhibiting wandering behaviors. The MDS coordinator stated that wandering may not have been observed during the assessment period, but the surveyor noted multiple documented instances of wandering during that time. Another resident, a female admitted for long-term care with a preferred language of Vietnamese, was marked as "rarely/never understood" on her MDS Annual Assessment, and the Brief Interview for Mental Status (BIMS) was not conducted. The Social Services Director attempted the assessment using a phone interpreter in Cantonese, which was not the resident's language, resulting in poor communication. The resident's family confirmed she only speaks Vietnamese and demonstrated during an interview that she could communicate effectively when interpreted correctly. The facility's policy requires accurate documentation of residents' medical, functional, and psychological status, which was not followed in these cases.