Failure to Provide Timely Social Services for Behavioral Transfer
Penalty
Summary
The facility failed to provide sufficient and timely medically-related social services to assist a resident with behavioral issues in transferring to a Veterans Affairs (VA) facility for a behavioral bed. The resident, who had diagnoses including high blood pressure, dementia, and insomnia, exhibited a pattern of aggressive and combative behaviors, including physical aggression toward other residents and staff, verbal abuse, and attempts to take items from other residents. Documentation shows that the resident was moved from a secured dementia unit to a non-secured LTC unit, after which the frequency and severity of behavioral incidents increased, resulting in multiple episodes of aggression and threats to staff and other residents. Despite the escalating behaviors and repeated incidents, there was a significant delay in the facility's social services department actively pursuing a transfer to the VA for specialized behavioral care. Initial efforts to contact the VA and initiate a transfer were documented, but after the departure of the original social worker, there was a nearly three-month gap before further transfer efforts resumed. During this period, the resident continued to display aggressive behaviors, including physical altercations and threats involving staff and other residents, and required multiple interventions from crisis services and law enforcement. The deficiency was identified based on the lack of timely and consistent social services intervention to facilitate the resident's transfer to a more appropriate behavioral care setting, as evidenced by the prolonged delay in follow-up and coordination with the VA. This failure to provide adequate social services support contributed to ongoing behavioral incidents and did not help the resident achieve the highest possible quality of life, as required by regulatory standards.