Failure to Provide Required Social Services Follow-Up After Room Change
Penalty
Summary
The facility failed to provide ongoing medically-related social services monitoring during the 72-hour adjustment period following a room change for a resident with severe cognitive impairment and psychiatric diagnoses. The resident had severe dementia with psychotic disturbances and an adjustment disorder with mixed anxiety and depressed mood, with an admission MDS showing severely impaired cognition (BIMS score of 4) and a need for supervision with transfers and ambulation. The resident’s care plan identified that the resident was adjusting to a new memory care environment, with interventions including reminiscence, discussion of meaningful family relationships, and opportunities for quiet, one-to-one visits. On the day of the incident, an LPN documented that the resident was intrusive in another resident’s room and followed that resident down the hallway, after which the resident was redirected, separated, placed on 15-minute safety checks, and moved to a new unit. Social services were notified, and a social worker met with the resident to show the new room and documented that the resident was confused by the change but not agitated or behavioral. The following day, another social worker documented an assessment of the resident’s adjustment to the room change, noting that the resident was adjusting well with no signs of anxiety or distress and stating that she would follow up two more times per protocol. However, review of the clinical record from 1/17/26 through 1/21/26 revealed no further social services follow-up notes for the resident during the required 72-hour adjustment period. The Administrator confirmed that facility policy and practice required social services staff to follow up with a resident for 72 hours after a room change to ensure a smooth transition and that social services did not complete the required follow-up after the initial post-move visit. The Administrator also identified that the responsible social worker was reassigned after the 1/16/26 visit and that the follow-up was missed during the transition to a new social worker, contrary to the facility’s Room Change policy, which directed that social services assess and document how the resident is adjusting and address any issues after relocation.
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