Failure to Provide Social Services for Resident Refusing Respiratory Care
Penalty
Summary
The facility failed to provide medically-related social services for a resident who was reviewed for respiratory services. Despite multiple documented instances of the resident refusing essential care, such as oxygen therapy, BiPAP/CPAP use, fluid restrictions, and showers, there was no evidence that the facility's social services department was involved to address these refusals. Nursing notes and care manager documentation repeatedly described the resident as noncompliant with prescribed treatments and care recommendations, and the resident's representative was informed of these refusals. However, the social services director confirmed they were unaware of the resident's ongoing refusals and had not been notified by nursing staff. Additionally, the care plan did not include any interventions to address the resident's refusal behaviors, and there was no documentation of social services exploring the reasons for the refusals or participating in care conferences regarding these issues. The resident's representative had requested to be notified of refusals so they could intervene, but reported not receiving further communication from the facility. The lack of social services involvement and absence of a behavior-focused care plan contributed to the deficiency, as the resident continued to refuse necessary care up until their passing.