Failure to Honor Resident's Goals of Care and Dietary Preferences
Summary
The facility failed to identify and promote individualized care for a resident who expressed clear goals of care and dietary preferences. The resident, who was cognitively intact and his own decision maker, repeatedly requested to discontinue thickened liquids and soft foods, preferring a regular diet and thin liquids to improve quality of life, despite understanding the associated risks. The clinical record showed that the resident and his family participated in assessment and goal setting, but there was no documentation of an interdisciplinary team meeting or collaboration to discuss the resident's goals of care. The resident experienced diarrhea attributed to the thickener, which further impacted his well-being, and both the resident and his spouse made multiple requests for a change in diet and consideration of comfort measures only (CMO) status. Despite these requests, facility staff, including the APRN and Social Worker, did not facilitate a meeting with the interdisciplinary team, the resident, or the family to address the resident's wishes. The APRN questioned the resident's and spouse's decision-making capacity without documented evidence and did not contact the resident's daughter, who was believed to be the legal decision maker. The DNS confirmed that no waiver was provided for the requested diet change and stated that the resident was not considered appropriate for CMO status. The facility did not provide a policy on the provision of social services when requested.
Penalty
Resources
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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.
Plan Of Correction
The facility will continue to provide SS support and document in medical record accordingly to ensure emotion needs and support of their residents. Resident #171 continue to reside at the facility. SSD followed up with resident #171 on 3/18/26 and documented in the medical record. Psych nurse practitioner assessed residents #171 on 3/19/26 with no changes noted to psychosocial wellbeing. Resident #171 denied any complaints and appeared calm and relaxed stating to the NP that she feels safe. Further SSD follow up was conducted on 3/27/26 with resident #171, no negative findings noted. On 4/6/26, the SSD conducted a psychosocial assessment on resident. On 4/8/26, Resident #171 care plan was reviewed by the IDT team. An initial audit was conducted of all current facility residents, by the Regional LISW-S, of the last 30 days ensuring SSD has proper follow up and documentation in medical record for changes in condition related to mood and behavior. Initial audit was completed on 4/6/26. The DON reviewed the facilities change in condition policy with SSD on 3/27/26. The Regional LISW-S, reviewed facility expectations for support of a resident with a change in condition and documentation requirements to ensure the psychosocial well-being of residents. Reeducation for facility SSD was completed on 3/31/26. A QA committee meeting was held on 4/8/26 reviewing survey results and findings, investigation and medical record documentation requirements, policy and procedures for abuse prevention and reporting abuse, SS policy and procedure, and facilities change in condition policy and procedure. Weekly for 2 weeks, or as directed by the QA committee, audits will be conducted by the Regional LISW-S all aspects of the resident's medical record including but not limited to: clinical and social service documentation, behavioral alerts and Point Click Care dashboard ensuring changes in condition are addressed by the SSD and documented accordingly. Negative findings will be corrected by reeducation and providing immediate support to residents. Negative findings will be reported to the QA committee for review. The Regional Administrator will ensure the weekly audits are completed. The Administrator is responsible for the ongoing compliance.
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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