Failure to Develop Baseline Care Plans for Non-English Speaking Residents
Penalty
Summary
The facility failed to create and implement a baseline care plan addressing communication needs for two residents who did not speak English and required interpreter services. Upon admission, both residents' Minimum Data Set (MDS) assessments indicated a preferred language other than English and a need for interpreter assistance to communicate with healthcare staff. Despite this, neither resident had a baseline care plan for communication or interventions for interpreter services within 48 hours of admission, as required. For one resident, a care plan was eventually created ten days after admission, but it still lacked interventions for interpreter services. The other resident did not have any care plan related to communication or interpreter services as of the date of the survey. Interviews with facility staff, including a licensed nurse and facility leadership, confirmed that interpreter services were not available and that staff were unable to communicate directly with the residents. In one instance, staff misinterpreted a resident's attempt to communicate and administered pain medication when the resident was actually trying to indicate they were cold. The administrator and DON acknowledged that baseline care plans should have been in place to address these residents' communication needs but were unable to provide evidence that such plans existed.