Failure to Provide and Document Psychosocial Follow-Up After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services and psychosocial follow-up to a resident after a resident-to-resident altercation. Facility policy on Abuse/Neglect/Exploitation requires protection of residents from physical and psychosocial harm during and after an investigation, including providing emotional support and counseling. The Social Services Director policy further requires identification and provision of medically related social services and adequate documentation of social services actions in the medical record. Despite these policies, there was no documented psychosocial assessment or follow-up for the affected resident after the incident. The incident occurred when one resident with dementia (R4) walked into the lobby and slapped another resident (R3) in the face while R3 was sitting in the lobby. Staff witnessed the event, immediately removed R4, and nursing assessed R3, documenting no physical injuries but noting that R3 was “shaken up.” The facility’s Misconduct Incident Report recorded that R3 was concerned she had done something wrong, required reassurance that she was safe, and continued to bring up the incident for a few hours afterward before forgetting about it. R3’s medical record, including a progress note from the date of the incident, documented the physical assessment and that she was shaken, but contained no follow-up documentation addressing her psychosocial needs related to the altercation. R3 had been admitted with dementia and associated psychotic, mood, and anxiety disturbances, and her most recent MDS showed moderate cognitive impairment. During interviews, the social worker stated she had heard about the incident but was not directly informed of her role, was unsure what her responsibilities would be, and acknowledged that any conversations she had with R3 about the incident were general and not documented. The DON and the Nursing Home Administrator both acknowledged awareness of the incident and indicated they would have expected psychosocial follow-up and documentation for R3 after the altercation. The absence of documented psychosocial assessment or follow-up, despite policies requiring such services and the resident’s expressed distress, formed the basis of the cited deficiency.
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