F0725

D

Failure to Provide Facility-Staffed 1:1 Supervision and Communication Support for a High-Acuity Resident

Glendale, Arizona Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure sufficient and appropriate staffing, including provision of a caregiver/sitter, to meet the individualized needs of a resident with significant cognitive impairment, language barriers, and behavioral symptoms. The resident was admitted with hemiplegia and hemiparesis following cerebral infarction, dysphagia, metabolic encephalopathy, diabetes, and gait abnormalities. On admission, the nursing assessment documented that the resident’s preferred language was not English, that it was unclear whether an interpreter was needed, and that the resident had slurred, sometimes understandable speech and could only sometimes understand others. A BIMS score of 1 indicated severe cognitive impairment. The baseline care plan identified an alteration in communication, language barrier, and aphasic, disorganized, and slurred speech, with an intervention for a speech therapy consult, but did not include use of a communication board, written communication, or translation application.

Over the following days, the resident exhibited repeated refusals of medications and blood sugar checks, falls, and escalating behavioral symptoms, while documentation showed limited or no use of interpreter tools and no timely care plan revisions. On one date, a provider notification note documented that the resident refused medications and blood sugar checks despite use of a language communication board, and staff were unable to verify understanding due to the language barrier; there was no evidence of attempts to use an interpreter or translator application. The resident experienced an unwitnessed fall and was unable to describe the event, yet the care plan showed no updates or added interventions after this fall. A second fall occurred with similar inability to describe the event, again without evidence of care plan revision. Subsequent nursing notes described the resident screaming, kicking, scratching staff, refusing care and medications, attempting to get out of bed unassisted, smacking staff, throwing equipment (including leg brace and sensor pad), and remaining combative and refusing all care and medications, with multiple entries lacking evidence of provider notification of these behaviors.

Later documentation showed that the resident had three unwitnessed falls in one evening, was very distressed, would not allow staff to touch her, and seemed unable to be safe, prompting provider notification and a psychiatric consult order. Notes indicated the resident barricaded herself in her room, staff had difficulty accessing her, and the physician ordered transfer to the hospital. After return from the hospital with no acute findings, the administrator documented a conversation with the resident’s son stating concerns about the resident’s safety and a need for a caregiver from late afternoon to early morning, and provided information for a private caregiver company. The care plan still contained no revision or intervention specifying a need for 1:1 sitter or caregiver during those hours. A later nursing note documented that the resident had direct 1:1 supervision with a private sitter, paid for by the family, with continued refusal of medications and assessments and no evidence of use of a communication board, interpreter, or translator application.

Interviews with staff and the administrator confirmed that the facility did not have an interpreter or translator service, relied on a basic picture sign for communication, and that the administrator believed the resident required care above what the facility could provide, specifically 1:1 sitter care. The administrator stated the facility could provide a sitter only for a very short period and otherwise referred families to private caregiver companies, and that he informed the resident’s son that the facility could not provide a sitter. The ADON stated that the facility did have staff who could act as sitters but that additional staffing required administrator approval, and that based on the record, the resident needed a sitter. Other nursing staff reported that the resident could sometimes be calmed and redirected and appeared appropriate for the facility, but also acknowledged uncertainty about the extent of the language barrier. The facility’s staffing policy stated that staffing is based on census and acuity, that the facility has the ability to hire sitters as needed, and that additional staff or agency personnel can be brought in when events require extra resources. Despite this policy, the record and interviews showed no evidence that the facility implemented or provided a facility-funded sitter or adjusted staffing to meet this resident’s identified need for 1:1 supervision, instead directing the family to hire and pay for a private sitter and proceeding with discharge while documenting that the resident’s needs could not be met in the facility.