Failure to Provide Timely Social Services Assessment and Discharge Planning
Penalty
Summary
The facility failed to provide sufficient and timely medically-related social services for a resident during the admission and discharge planning process. Facility policy required a social assessment to be completed within fourteen days of admission to identify the resident's needs and to assist in developing a personalized care plan. However, the resident's clinical record showed that the Social Services Evaluation at admission was left blank, and there was no documented social service assessment during the resident's stay. This omission meant that the resident's personal and social needs, as well as potential problems, were not formally identified or addressed as part of the care planning process. The resident in question was admitted with multiple diagnoses, including atrial fibrillation, dementia with behavioral disturbance, repeated falls, and generalized muscle weakness. Throughout the stay, progress notes indicated ongoing confusion and a need for 24-hour support due to dementia. The care plan included a focus on cognitive decline, impaired vision, communication problems, self-care deficits, limited mobility, and a desire to discharge back to the community. Despite these complex needs, there was no documentation of social services involvement in discharge planning, such as arranging for home health services, private duty care, or ensuring that the resident's transition back to the community was safe and supported. Upon discharge, documentation was incomplete regarding the arrangements made for the resident's care at home. The discharge summary noted a referral for home health but did not include the agency's name or contact information, nor did it specify the resident's living arrangements or confirm that necessary services were in place. Interviews with facility leadership revealed that social service activities were being covered by the NHA and Admissions Coordinator due to a vacancy in the social worker position, and that key documentation and assessments were missed. There was no evidence of a review or assessment of the discharge plan to ensure the resident's needs would be met after leaving the facility.