Failure to Provide Medically Related Social Services for Resident with Self-Harm and Behavioral Issues
Penalty
Summary
The facility failed to provide medically related social services to a resident with a history of self-harm, mood disorders, and repeated 911 calls. The resident, who had diagnoses including hemiplegia, hemiparesis, and bipolar disorder, expressed dissatisfaction with care, reported thoughts of suicide, and had multiple documented incidents of agitation, resisting care, and self-harming behaviors such as hitting themselves and banging their head against the wall. Despite these behaviors and repeated emergency calls, there was no evidence of follow-up or intervention from the social services department after an initial note in March, nor was there documentation of assessment or discussion regarding the root causes of the resident's actions. The resident's clinical record showed frequent calls to 911 for various complaints, resulting in multiple hospital transfers, but there was no documentation of any attempt by staff to determine the underlying reasons for these calls. Psychiatric evaluations were conducted, but they did not address the repeated emergency calls or incidents of self-harm. The care plan for the resident was not updated to reflect new or escalating behaviors, and no new interventions were implemented after the resident exhibited self-harming actions. Interviews with facility staff, including the Administrator, DON, and Social Services Director, revealed a lack of awareness and communication regarding the resident's suicidal ideation and self-harming behaviors. The Social Services Director was unaware of these incidents and had not provided follow-up or interventions. The Administrator acknowledged that there should have been documented follow-up and interventions after the resident's return from the hospital, but none were present in the record.