Failure to Provide Sufficient Social Services for Resident with Behavioral Health Needs
Penalty
Summary
The facility failed to provide sufficient and timely social services to meet the needs of a resident with a history of depression, morbid obesity, diabetes, and atrial fibrillation. The resident had documented behavioral issues, including yelling, verbal aggression, threats of self-harm, and physical aggression toward staff and other residents over a six-month period. Despite these ongoing behaviors and a diagnosis of depression with a history of suicidal thoughts, the social services documentation showed only routine assessments and brief check-ins, with no evidence of attempts to provide, arrange, or request behavioral health or ancillary services to address the resident's escalating behaviors. The resident's care plan acknowledged socially inappropriate and disruptive behaviors, such as verbal aggression and inappropriate touching, but did not include interventions or referrals for behavioral health assistance related to the resident's threats and actions of self-abuse, physical, and verbal abuse toward others. Physician orders indicated a need for social services consultation for aggressive and combative behavior, but there was no documentation that such services were provided or arranged. The social worker's notes primarily reflected general well-being checks and did not address the specific behavioral incidents or the need for specialized behavioral health support. Interviews with facility leadership confirmed the lack of sufficient and timely social services for the resident. The clinical record lacked evidence of any proactive measures by the social worker to address the resident's behavioral health needs, despite multiple documented incidents of aggression, threats, and self-harm. This failure to provide appropriate social services was found to be out of compliance with state regulations regarding resident rights, social services, and nursing services.