Failure to Provide Medically-Related Social Services and Behavioral Interventions
Penalty
Summary
The facility failed to provide medically-related social services to help residents achieve the highest practicable physical, mental, and psychosocial well-being, as evidenced by multiple incidents involving several residents. One resident with severe cognitive impairment and a history of dementia, mood disturbances, and psychotic disturbances exhibited escalating aggressive behaviors, including multiple physical altercations with staff and other residents. Despite repeated incidents, the facility did not consistently conduct root cause analyses, reassess behavioral interventions, or implement new person-centered strategies to address the resident's psychosocial and behavioral needs. Documentation showed that interventions were not evaluated for effectiveness, and there was a lack of follow-up by social services after significant behavioral events. Other residents were also affected by the facility's deficient practices. For example, one resident repeatedly entered another resident's room, sometimes inappropriately disrobed, causing distress and fear. The intervention of a stop sign banner was inconsistently applied, and there was no evidence of reassessment or follow-up with the affected resident regarding their psychosocial needs after the incidents. Additionally, another resident expressed feeling unsafe following a violent altercation but did not receive any follow-up or assessment from social services. In another case, a resident with a history of elopement and verbalizations of wanting to leave the facility did not have their psychotherapy updated or alternative placement options explored, despite ongoing expressions of frustration and feeling like a prisoner. The facility's own assessment documents indicate an expectation to provide person-centered care, including behavioral and mental health interventions, yet the actions taken did not align with these stated competencies. The lack of timely and thorough social services assessments, failure to update care plans, and insufficient follow-up after behavioral incidents contributed to an environment where residents' psychosocial and safety needs were not adequately addressed. These failures resulted in a pattern of deficient practice affecting multiple residents.
Removal Plan
- NHA educated Social Worker on the following policies: Definition of F745 Medically related social services from CMS, Members Behavior Policy, Member to Member altercation policy, Care planning policy, Trauma informed Care Policy, Root Cause Analysis process, Member mood assessment policy, Member discharge policy, Member at risk for elopement or unsafe wandering policy
- SDC/Designee educated Staff on Member Behavior policy, Member to member altercation policy, care planning policy and member at risk for elopement or unsafe wandering policy
- Social worker attended the Wisconsin Nursing Home Social Workers Association fall conference
- Social Worker/Designee to follow up with members or POA-HC or Guardian in discharge planning per member discharge policy for members wishing to discharge from facility
- Nurse Managers/Designee to complete elopement assessment for members due for quarterly assessment or with current change of condition warranting updated elopement assessment
- Social worker will establish a mentorship relationship with a licensed clinical social worker at the Wisconsin Veterans Home at King with weekly mentorship meetings. Facility will also pursue professional services for social services consulting
- The facility implemented a system/procedure to review every behavior event, resident-to-resident altercations, and elopements during morning clinical which included reviewing assessment and care plan interventions for appropriateness
- Social Worker/Designee will review progress notes in clinical meeting auditing for members with increased behaviors, exit seeking, wishes to discharge and trauma. Those members identified will be adequately assessed and interventions put in place. Findings will be reported to QA for further recommendations
- Social Service Director and Administrator to conduct weekly meeting to review Medically Related Social Services concerns and establish process for addressing concerns