Failure to Develop and Implement Person-Centered Care Plans for Non-English Speaking Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents whose primary language was Spanish. Both residents had moderate cognitive impairment and significant medical and functional needs, including assistance with activities of daily living, mobility impairments, incontinence, and multiple chronic medical conditions. Despite these needs and the residents' inability to communicate in English, their care plans did not include communication strategies or materials in Spanish, nor were there communication boards or devices available in their rooms to facilitate understanding between staff and residents. Observations and interviews revealed that staff members, including CNAs and RNs, did not speak Spanish and relied on phone translation apps or Spanish-speaking staff when available. However, there was no consistent or systematic approach to ensuring effective communication with Spanish-speaking residents. Communication boards were only available at the nurses' station and therapy room, not in the residents' rooms, and staff were not uniformly trained on how to use translation tools or communication aids. Several staff members confirmed the absence of communication binders or boards in the rooms of non-English speaking residents, and some were unaware of the need for such resources. The facility's own care plan policy requires the interdisciplinary team (IDT) to develop care plans based on comprehensive assessments, including the resident's preferences and needs. However, interviews with the DON, MDS coordinator, and other staff indicated that care plans addressing language and communication needs for Spanish-speaking residents were not created until prompted by surveyor inquiries. The lack of timely and appropriate care planning for communication placed these residents at risk of having unmet needs due to language barriers.