Failure to Provide Medically-Related Social Services and Ensure Resident Rights
Penalty
Summary
The facility failed to provide medically-related social services to help each resident achieve the highest possible quality of life, as evidenced by a lack of proper interdisciplinary team (IDT) participation in care plan meetings and failure to assist residents in asserting their rights related to abuse, neglect, and person-centered care planning. Record reviews showed that care plan meetings were often attended only by social services and activities staff, without the required participation of clinical, dietary, therapy, or nursing representatives. This was confirmed by both the Nursing Home Administrator and the Director of Nursing, who acknowledged that the IDT was not participating as required, and that only social services and activities staff, who shared an office, were regularly present. Additionally, the facility's grievance review revealed multiple allegations of abuse and neglect over a 12-month period, including reports of residents being left in soiled clothing, rough handling by staff, delayed call bell responses, and lack of proper hygiene care. These grievances were reported to social services, nursing, or other staff, but a review of the facility's reportable log found that none of these allegations had been documented or reported as required. The Nursing Home Administrator confirmed that if the allegations were not on the log, they had not been reported, and agreed that these incidents should have been reported. The deficiencies affected a significant number of residents, as evidenced by the number of grievances and care plan records reviewed. The facility's own policies required the presence of a full interdisciplinary team at care plan meetings and proper documentation of attendees, which was not followed. The lack of IDT participation and failure to report abuse or neglect allegations represent a breakdown in the facility's processes for ensuring resident rights and comprehensive, person-centered care planning.