Failure to Provide Medically-Related Social Services for Resident Transfer
Penalty
Summary
The facility failed to provide medically-related social services to assist a resident, identified as Resident R1, in achieving her goal of transferring to another facility. Resident R1, who was cognitively intact with a BIMS score of 15, expressed dissatisfaction with the current facility and a desire to transfer since her admission. Despite her daughter's request for assistance from the social worker on November 15, 2024, and subsequent documentation in nursing and physician progress notes, the social services department did not initiate or complete the necessary discharge planning to facilitate the transfer. The social worker, Employee E5, was unaware of Resident R1's request until an interview on December 5, 2024, indicating a lack of communication and follow-up on the resident's needs. The care plan initiated on November 15, 2024, did not include a discharge plan to another facility, and there were no further notes or follow-up actions documented by the social worker. Interviews with the Director of Nursing and the Unit Manager confirmed the oversight, highlighting a deficiency in the facility's provision of social services as required by regulations.
Plan Of Correction
Resident R1 was assisted by the NHA and Admissions Coordinator at her daughter's request to have her mother transferred to two specific facilities in which the daughter chose. Unfortunately, both facilities denied the resident. A subsequent conversation occurred with the daughter who is the POA to discuss options. The daughter stated that she would choose the nursing home based on location from her and other family members but never provided the facility with any information. R1 was discharged to her daughter's care to live at home. All residents can be affected by this deficient practice. A comprehensive education will be provided to the Interdisciplinary Team and the Social Worker director by the LNHA on the provisions of F-745 to ensure compliance. Requests for discharges will be discussed during the daily operations and clinical meetings to ensure the Social Services Department is aware of requests for resident transfers and assists with the details of the transfers. The Nursing Home Administrator will audit requests related to transfer requests to other facilities weekly for 4 weeks then monthly for one month to ensure compliance. The results of these audits will be reviewed with the IDT during the monthly QAPI meetings to ensure compliance.