Failure to Implement Communication Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to implement an effective communication care plan for a resident with severe cognitive impairment and limited English proficiency. The resident, who speaks Haitian-Creole and has diagnoses including dysphagia, dementia, diabetes mellitus, and mild cognitive impairment, was observed during multiple meal times where staff did not attempt to communicate in the resident's preferred language. Staff members spoke only in English, did not use communication boards, and did not utilize interpreter services or language lines, despite the facility's policy requiring meaningful access for individuals with limited English proficiency. Care plans and the Kardex indicated that staff should use simple questions and face-to-face communication, and the facility's policy emphasized the need for language access. However, during observations, staff did not follow these interventions, and interviews revealed a lack of awareness or use of communication aids. The Director of Nursing confirmed the expectation that staff communicate in the resident's preferred language, but this was not observed in practice.