Failure in Discharge Planning for a Resident
Summary
The facility failed to provide medically related social services to ensure the highest practicable well-being for a resident, identified as Resident 28. The resident, who was admitted in May 2023, was assessed to have no cognitive impairment and was independent in most activities of daily living (ADLs), except for bathing. Despite expressing a desire to live elsewhere, the resident did not receive assistance with discharge planning. Interviews revealed that the social services staff had not documented any inquiries for alternate living arrangements, nor had they contacted the State Social Worker to assist with discharge planning. Additionally, there was no Level 2 PASRR completed to determine if specialized mental health services would be beneficial for the resident's appropriate placement. Observations and interviews with staff indicated that the resident was functionally independent and capable of performing ADLs such as bed mobility, transfers, and personal hygiene. However, the resident's mental health issues were noted to interfere with her ability to live independently. Despite this, there was no documented effort to explore less restrictive environments, such as an adult family home, which staff believed would be suitable for her. The lack of documented discharge planning and failure to engage necessary resources placed the resident at risk for a decreased quality of life.
Penalty
Resources
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A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with CHF, history of DVT, and chronic lymphedema was care planned for monitoring of SOB, chest pain, edema, and elevated B/P, and multiple NP and physician notes documented that the resident, on diuretics, needed outpatient follow-up with a lymphedema clinic. Review of the clinical record showed no order or attempt to schedule this follow-up appointment. In interviews, an RN and the Nursing Home Administrator confirmed that the resident did not receive the needed lymphedema clinic appointment, resulting in a deficiency under 28 Pa. Code 211.16(a) for failure to provide necessary medically-related social services.
Three residents with dysphagia, G-tubes, neurologic conditions, and complex medical needs had physician-ordered Modified Barium Swallow (MBS) studies and ENT or Barium Swallow consults that were not properly scheduled or documented by the Social Services Director (SSD). Nursing staff documented that the physician issued the orders and that Social Services was notified, and the ST confirmed that the residents and responsible parties had agreed to the testing. The SSD acknowledged receiving the orders, attempting to contact responsible parties, and working on insurance authorization, but kept notes on paper in a personal folder and used a temporary EMR communication board instead of documenting referrals, scheduling efforts, refusals, or delays in the permanent EMR. Facility policy required Social Services to coordinate physician-ordered referrals and document them in the medical record, but there was no EMR evidence that the ordered tests and consults were completed, scheduled, or appropriately followed up, resulting in delayed care and unmet medically related social service needs.
The facility failed to ensure timely follow-up on a guardianship process for a cognitively impaired resident with multiple chronic conditions, despite an expert evaluation recommending guardianship and prior agreement to initiate it. The social worker submitted a referral to the county probate investigator and later sent correspondence to inquire about services, but no further documentation of progress or outcome was recorded for many months. The Director of Social Services reported believing the process was delayed due to the resident owning a house and acknowledged she had not followed up after her last note, while the Regional Business Office Manager was unaware of any housing barrier and had asked the social worker to follow up. This inaction did not align with the Social Service Director’s job description, which required coordinating services and performing resident advocacy, including applications for supplementary services.
A resident with severe cognitive impairment, depression, dementia, and multiple medical conditions alleged sexual abuse by a CNA and exhibited upset and guarded behavior when questioned about the incident. Although a social worker designee and another staff member interviewed the resident and the social worker designee reported multiple follow-up contacts to assess emotional and cognitive status, there was no documentation of the allegation, the psychosocial change, or any social services assessments or notes in the medical record for the period following the event. This failure to document conflicted with the social worker designee’s job responsibilities to accurately record psychosocial needs, interactions, and follow-up actions.
A resident with advanced dementia and schizoaffective disorder, who had severely impaired cognition (BIMS score of 0) and was rarely/never understood, had documented needs for emotional support, care coordination, and advocacy, as well as care plan interventions for expression of thoughts and feelings and provision of psychiatric services. However, required SW documentation was missing, including quarterly progress notes for an eight-month period and an annual assessment for over a year, with the sole SW acknowledging these were missed due to oversight and no SW documentation/assessment policy provided when requested.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Failure to Arrange Ordered Lymphedema Clinic Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services by not arranging a needed follow-up appointment with a lymphedema clinic for one resident. The resident was admitted with diagnoses including heart failure, a history of DVT, and lymphedema. An MDS dated 2/26/26 documented these conditions, and the care plan for high blood pressure and CHF directed staff to observe for signs and symptoms such as SOB, chest pain, edema, and elevated blood pressure. The care plan for actual/potential risk for skin integrity impairment was updated on 3/6/26 to include lymphedema. Multiple provider notes documented the need for a lymphedema clinic follow-up. A nurse practitioner’s note dated 2/24/26 listed lymphedema and specified that the resident, who was on diuretics, needed follow-up with a lymphedema clinic. A physician’s note dated 2/25/26 and another nurse practitioner’s note dated 3/3/26 both reiterated that the resident had chronic lymphedema, was on diuretics, and needed outpatient follow-up with a lymphedema clinic. Review of the clinical record showed no order for this appointment and no attempt to schedule it. In interviews, an RN confirmed the resident was not provided a follow-up appointment, and the Nursing Home Administrator confirmed the facility failed to schedule the follow-up, constituting noncompliance with 28 Pa. Code 211.16(a) regarding social services.
Failure to Schedule and Document Physician-Ordered Swallow Studies and Consults
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services by not ensuring that physician-ordered consultations and diagnostic tests were scheduled and properly documented for three residents. For one resident with COPD, dysphagia, and altered mental status, a physician ordered a Modified Barium Swallow (MBS) to rule out silent aspiration. Nursing notes documented that the physician made rounds, examined the resident, and issued the MBS order, and that Social Services was notified. The assigned LVN stated that the Social Services Director (SSD) was responsible for scheduling the MBS after receiving the order and that nursing did not typically follow up once the order was handed off. However, there was no documentation in the electronic medical record (EMR) that the MBS was scheduled, completed, refused, or that any follow-up attempts or contacts with the resident or responsible party occurred. Another resident with seizures, dystonia, a history of traumatic brain injury, and a gastrostomy tube had a physician’s order dated 7/22/25 for a Barium Swallow consult. Nursing notes indicated that the physician examined the resident and issued a new order for the Barium Swallow consult and that the Social Services Assistant was notified. The LVN stated that the resident had swallowing issues and received nutrition and medications via G-tube because he was not safe to eat or drink by mouth, and that Social Services should have scheduled the appointment and documented follow-up in the EMR. The Speech Therapist (ST) confirmed that this resident had an MBS ordered to assess whether he could tolerate an oral diet and reported that she followed up with the SSD months later and was told the SSD was still working on scheduling the test. The SSD later stated she had contacted the resident’s sister because the hospital required the responsible party to attend the appointment, and that she called the sister several times but did not document any of these attempts or contacts in the EMR. A third resident with hemiplegia and hemiparesis following cerebral infarction, dysphagia, aphasia, and a G-tube had physician’s orders dated 12/10/25 for an ENT consult to assist with vocal cord mobility and for an MBS to rule out silent aspiration and determine if a by-mouth diet was possible. The LVN stated this resident had been dependent on G-tube feeding on admission and had progressed to an oral diet while in the facility, and that the MBS was ordered to ensure he could safely tolerate oral intake. The ST stated she was treating this resident and that he needed an MBS to confirm he could tolerate an oral diet without aspirating and also needed an ENT consultation to help with communication. The SSD stated the resident had been scheduled for an in-house ENT consultation but discharged before the appointment, and that the MBS had not been scheduled because they were waiting for the ENT consult and insurance authorization. The SSD acknowledged she did not document the appointment, her attempts to obtain authorization, or any notifications to the ST or primary physician in the EMR. Across these three residents, the SSD described a process in which physician orders were delivered to her, sometimes placed under her office door, and she would then begin scheduling. She admitted she did not document attempts to schedule appointments or follow-up notes in the EMR, instead keeping papers with orders and handwritten notes in a folder in her office, and that when she did enter information into the EMR it was in a communication section that was automatically cleared and not part of the permanent medical record. The SSD stated that if something was not documented, it was considered not done, and acknowledged she should have documented her efforts in the EMR. The facility’s policy and procedure for Social Services referrals required Social Services to collaborate with nursing and other disciplines to arrange physician-ordered services and to document the referral in the resident’s medical record. The DON and Administrator both stated that the SSD was responsible for scheduling such appointments and that appointment scheduling and follow-up notes needed to be part of the resident’s medical record, but they were unaware that the SSD had not scheduled the ordered tests and consultations or documented her actions in the EMR. The surveyors concluded that these failures caused a delay in care and had the potential for the residents’ needs to go unmet.
Failure to Follow Up on Guardianship Process for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide medically-related social services by not timely arranging and following up on guardianship for Resident #78 as recommended by an expert evaluation. Resident #78 was admitted on 03/22/23 with multiple diagnoses including chronic myeloid leukemia, COPD, chronic heart failure, aphasia, dementia, epilepsy, spondylosis, gout, and depression, and had moderately impaired cognition per the comprehensive MDS 3.0 assessment. A hospital social work discharge summary documented that the hospital social worker had spoken with the facility about starting guardianship and the facility agreed. An expert evaluation completed on 03/05/25 concluded that guardianship should be established or continued for this resident. Progress notes showed that on 04/24/25 the facility social worker submitted a referral to the county probate investigator following the expert evaluation, and on 07/08/25 the social worker sent correspondence to the county probate office to inquire about services and the prior referral, noting she was waiting on a response and would update the facility team and discuss next steps. However, from 07/09/25 to 03/23/26 there was no additional documentation in the medical record regarding the resident obtaining a guardian. In interviews, the Director of Social Services stated she believed the guardianship process had been delayed due to the resident having a house that had not been previously known, acknowledged she did not know if this had been followed up since her 07/08/25 note, and later confirmed she had no further information and had not followed up after submitting information for guardianship. The Regional Business Office Manager reported being unaware of any housing situation that would prevent guardianship and stated she had asked the social worker to follow up. The facility’s Social Service Director job description required planning, assessing, coordinating, and implementing services to enhance residents’ social and psychosocial well-being and performing all duties involved in resident advocacy and applications for supplementary services, which was not met in this case.
Failure to Provide and Document Medically Related Social Services After Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to provide and document medically related social services for a resident who experienced a significant psychosocial event related to an allegation of staff-to-resident sexual abuse. The resident, admitted with multiple diagnoses including stroke, depression, dementia, and severe cognitive impairment, required extensive assistance with mobility and had a care plan for mood and behavioral alterations, including delusional thinking and yelling out. Despite this, there was no documentation in the medical record of the alleged sexual abuse incident, no social services notes, and no psychosocial assessments entered between 03/10/26 and 03/19/26. The quarterly MDS showed severe depression with no documented change since the prior assessment, and the behavior and mood assessments reflected no behaviors since the prior annual assessment, despite the reported allegation. During an interview, the resident became guarded and defensive when asked about the alleged abuse, reported being told by the Administrator and police officers that she was safe and that the male staff member would no longer care for her, and refused to elaborate further. The social worker designee reported being informed of the allegation by an LPN, interviewing the resident when she was upset and yelling about a man trying to put his “thing” in her mouth, and confirming the description of the alleged perpetrator matched a CNA on duty. The social worker designee stated she met with the resident several times after the alleged incident to follow up on her emotional and cognitive status and to check in with her, but acknowledged she did not document the resident’s behaviors or allegations on the date of the incident, nor any follow-up visits or updated psychosocial assessments. This lack of documentation and failure to accurately record psychosocial needs and interactions conflicted with the written job responsibilities for the social worker designee.
Failure to Provide and Document Required Social Work Services
Penalty
Summary
The facility failed to provide and document medically-related social services for a resident with dementia and schizoaffective disorder. The resident had a POA for health decisions and was documented in an annual social work (SW) assessment as being primarily alert to self with cognitive deficits related to place and time, as well as confusion. The annual assessment noted that the SW was available for emotional support and for concerns or complaints. A subsequent SW quarterly assessment documented that the resident continued to have severe cognitive impairment due to advanced dementia, with stable mood, calm and friendly affect, and poor insight and judgment, and stated that the SW would remain available for ongoing support, care coordination, and advocacy for the resident’s needs and comfort. The resident’s MDS showed severely impaired cognition with a BIMS score of 0 and that the resident was rarely or never understood. The resident’s care plan identified long-term care needs and psychiatric diagnoses of schizoaffective disorder and bipolar disorder, with interventions including encouraging the resident to express thoughts and feelings, providing support and validation as needed, and providing psychiatric services within the facility. Despite these identified needs and planned interventions, the clinical record lacked required SW documentation. There were no SW quarterly progress notes for an eight-month period following the last note dated 7/2/25, and no SW annual assessments for a period of one year and four months following the last annual assessment dated 11/13/24. The DNS confirmed there were no additional SW notes in the resident’s record. In an interview, the sole facility SW acknowledged that the resident’s annual and quarterly progress notes had been missed due to an oversight, noted that the electronic medical record did not prompt her to document, and stated that progress notes should be completed at least quarterly and annually. When requested, the facility did not provide a SW documentation and assessment policy.
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