Failure to Provide Behavioral Health and Social Services for Residents with Odor Issues
Penalty
Summary
The facility failed to provide necessary behavioral health care and social services for two residents whose room odors were significant enough to permeate surrounding halls, affecting other residents, visitors, and staff. For one resident with diagnoses including morbid obesity, alveolar hypoventilation, and type 2 diabetes, there were repeated observations of strong, foul odors emanating from the room. The resident was cognitively intact and required varying levels of assistance with self-care and toileting. Documentation showed a history of refusing care and treatments, and the care plan included psychosocial monitoring and interventions. However, social services progress notes lacked evidence that the social worker was aware of or addressed the odor issue, and there was no documentation of interventions related to this matter until after it was brought to their attention during the survey. Another resident, diagnosed with neuromuscular bladder dysfunction, lumbar spina bifida with hydrocephalus, and morbid obesity, was also found to have a strong urine odor in and around the room. This resident was cognitively intact and required supervision and assistance with ADLs. The resident admitted to soiling the bed and only requesting assistance when necessary, and preferred minimal disturbance. The care plan noted risks related to mood and behavior, with interventions for monitoring and emotional support, but social services documentation did not show awareness of or action on the odor issue. The quarterly care conference also failed to mention the odor, focusing only on routine bathing. Interviews with the corporate and covering licensed social workers revealed that the facility did not have a dedicated social worker or designee at the time, and the two were sharing responsibilities. Both residents had declined certain behavioral health referrals, but there was no evidence of further social services interventions or documentation addressing the ongoing odor issues. Requested policies for social services assessment and intervention were not provided.