Failure to Provide Timely Social Services Support After Resident-to-Resident Abuse
Summary
The facility failed to provide timely social services support to residents involved in resident-to-resident abuse incidents. Five residents were reviewed for such incidents, and it was found that the facility did not ensure that social services met with the residents within the required timeframe. For instance, Resident #1, diagnosed with paranoid schizophrenia and other disorders, was involved in an incident on 8/7/24 but was not met by social services until the following day. Subsequent follow-ups were also lacking, as there were no social service notes from 8/9/24 through 8/11/24 and from 8/13/24 through 8/20/24. Resident #2, who has vascular dementia and other behavioral issues, was also involved in the same incident on 8/7/24. However, there was no documentation of any social worker interaction with this resident regarding the incident throughout the entire month of August. Social Worker #1 admitted to not remembering meeting with the resident, which resulted in the absence of documentation. This lack of timely intervention and documentation was a recurring issue for other residents involved in similar incidents. Residents #3, #4, and #5 also experienced deficiencies in social services follow-up after incidents of resident-to-resident abuse. For example, Resident #3 was involved in an incident on 8/30/24, but follow-up documentation was missing from 9/1/24 through 9/8/24. Similarly, Resident #4, involved in the same incident, had no further social service documentation after the initial meeting on 8/30/24. The facility's social workers failed to consistently meet with residents within 24 hours of incidents and did not follow up daily for the required 72 hours, as confirmed by interviews with the social workers and the facility administrator.
Penalty
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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 cognitive deficits and a history of combative behavior was not provided with adequate podiatry care due to repeated refusals, lack of family notification, and insufficient documentation by untrained social services staff. The staff member responsible had not received formal training or a job description, resulting in prolonged neglect of the resident's toenail care.
A resident with a history of depression, anxiety, and alcohol dependence was unable to attend AA meetings due to a broken facility van, and no alternative support or social services were provided during this period. The resident, who relied on AA for social interaction and emotional support, did not receive follow-up or in-house interventions from the social worker or other staff, despite clear care plan directives and facility policy requirements.
A resident with severe cognitive impairment and multiple psychiatric and physical diagnoses did not receive necessary medically related social services after the resignation of their legal guardian. Staff were unaware of who was responsible for the resident's care decisions, financial matters, or Medicaid redetermination, and the medical record contained outdated contact information and instructions. This resulted in the resident lacking appropriate representation and support.
A resident with paraplegia and other medical conditions repeatedly requested assistance from the social worker to transfer to another facility closer to a preferred location. Despite these requests and the resident's intact cognition, there was no evidence that the social worker made any attempts to contact other facilities or document follow-up actions, instead relying on the resident's mother to find a new placement.
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 Adequate Social Services and Podiatry Care Due to Untrained Staff
Penalty
Summary
The facility failed to ensure that social services staff were adequately trained and performed their duties as required, specifically affecting one resident with a history of traumatic brain injury, aphasia, and cognitive deficits. This resident was rarely understood, had self-care deficits, and exhibited combative behaviors during personal care, including resistance to nail care by both staff and an outside podiatrist. Despite repeated refusals of podiatry care and ongoing issues with extremely long, thick, and curled toenails, there was no documentation that the resident's family was notified of these refusals, nor was there evidence that these issues were discussed during care conferences. Observations confirmed the resident's toenails had been neglected for an extended period, and the podiatrist noted the condition may have persisted for years. Further review revealed that the staff member responsible for social services, who also served as the Activities Director, had not received official training for the social services role, had not been provided with a job description, and was unaware of all required duties. The personnel file lacked a signed job description, and the staff member admitted to learning the role informally and not documenting care refusals or family notifications as required. Facility policy required proper treatment and care to maintain foot health, but this was not followed in the resident's case.
Failure to Provide Medically-Related Social Services for Psychosocial Well-Being
Penalty
Summary
The facility failed to provide medically-related social services to support a resident's psychosocial well-being, specifically for a resident with a history of major depression, anxiety disorder, and alcohol dependence in remission. The resident was identified as being at risk for psychosocial issues due to social isolation, depression, and physical limitations, and his care plan included interventions such as access to psychiatric services and opportunities for social engagement. Despite these identified needs, the resident was unable to attend Alcoholics Anonymous (AA) meetings, which he considered his primary source of social interaction and support, after the facility's transportation van broke down. Interviews revealed that the resident missed multiple AA meetings due to the lack of transportation, and no alternative arrangements were made to support his psychosocial needs during this period. The resident reported not being aware of the facility's social worker and stated that no one had offered him additional support while he was unable to attend AA. The social worker acknowledged not following up with the resident or providing in-house services to address his needs during the transportation disruption. Other staff members confirmed the importance of AA meetings to the resident's well-being and noted a decline in his mood when he was unable to attend. The facility's social services job description outlined responsibilities for addressing residents' emotional adjustment and ensuring appropriate psychosocial interventions, but these were not fulfilled in this case. The lack of timely and appropriate social services intervention resulted in the resident not receiving the support necessary to maintain his highest possible quality of life, as required by facility policy and regulatory standards.
Failure to Provide Medically Related Social Services Due to Lack of Legal Representation
Penalty
Summary
The facility failed to provide medically related social services necessary for a resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The resident in question had multiple complex diagnoses, including schizoaffective disorder, alcohol-induced dementia, bipolar disorder, delusional disorders, hearing loss, and legal blindness. The resident was severely cognitively impaired, dependent on staff for all activities of daily living, and unable to participate in meaningful conversation or provide reliable information. Despite these needs, the facility did not ensure that the resident's legal and social service needs were met, as evidenced by outdated and incorrect emergency contact information and a lack of clarity regarding who was responsible for making decisions on the resident's behalf. Interviews and record reviews revealed that the social worker and other staff were unaware of who was responsible for the resident's care decisions, financial matters, or Medicaid redetermination after the resignation of the legal guardian. The medical record still directed staff to refer to a legal guardian who was no longer in place, and there was no active case with Adult Protective Services. The social worker confirmed that multiple staff failed to update the resident's records and ensure appropriate representation, resulting in a lack of necessary social services and support for the resident.
Failure to Provide Social Services for Resident Transfer Requests
Penalty
Summary
The facility failed to ensure that medically-related social services were provided to assist a resident in achieving the highest possible quality of life, specifically by not supporting the resident's repeated requests to transfer to another facility. The resident, who had diagnoses including paraplegia, unspecified protein-calorie malnutrition, generalized anxiety, and chronic respiratory failure, was cognitively intact and had clearly expressed his desire to move closer to a specific location during multiple care conferences. Documentation showed that the resident's preference to transfer was discussed on several occasions, with the social worker assigned to assist in finding a suitable facility. Despite these documented requests, there was no evidence in the medical record that the social worker made any attempts to contact facilities in the desired area over an extended period. Interviews confirmed that the social worker was aware of the resident's wishes but relied on the resident's mother to identify a new facility, even though the resident was his own responsible party. The social worker also acknowledged that there was no documentation of follow-up actions taken to facilitate the transfer, which was a required responsibility according to the job description.
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