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F0745
D

Failure to Provide Medically Related Social Services Due to Lack of Legal Representation

Cleveland, Ohio Survey Completed on 09-02-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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these needs, the facility did not ensure that the resident's legal and social service needs were met, as evidenced by outdated and incorrect emergency contact information and a lack of clarity regarding who was responsible for making decisions on the resident's behalf.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.

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