Missed Quarterly Social Service Assessment for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to follow its policy and procedure for conducting timely social service assessments for a resident with dementia care needs. Specifically, the Social Service Director (SSD) did not complete a required quarterly social service assessment for a resident who had been admitted and readmitted with diagnoses including pneumonia, Parkinsonism, and schizophrenia. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and total dependence on staff for daily activities. The last social service assessment was conducted in January, but the quarterly assessment due in March was missed because the SSD was backed up with assignments for other residents. Interviews with the SSD and the Director of Nursing (DON) confirmed that quarterly and annual social service assessments are required by facility policy. The SSD acknowledged the omission and explained that the assessment includes evaluating psychosocial history, physical, cultural, and spiritual factors, as well as discharge planning. The facility's policy, last reviewed in July, outlines the requirement for timely and appropriate resident assessments, including quarterly assessments, which was not followed in this instance.