F0745

D

Failure to Provide Medically-Related Social Services After Resident-to-Resident Incidents

West Bloomfield, Michigan Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide medically-related social services to address psychosocial well-being, behavioral needs, and follow-up after resident-to-resident incidents for two residents with dementia and mood disorders. One resident (R35) had vascular dementia with severe cognitive impairment, verbal behavioral symptoms toward others, and documented episodes of swearing, resisting care, and verbal and physical aggression toward a roommate. Another resident (R49) had major depressive disorder, generalized anxiety disorder, unspecified dementia with behavioral disturbance, and adjustment disorder, with documented episodes of yelling, verbal aggression, threatening behavior, and refusing care. The facility became aware of an allegation that R49 had been physically and verbally assaulted by R35, and later documentation described R35 becoming verbally aggressive and physically violent with a roommate, including an observation of attempting to hit the roommate through the curtain.

Despite these incidents and the residents’ known behavioral and psychosocial conditions, the social services documentation was incomplete and lacked evidence of assessment and follow-up. For R35, social service progress notes since December consisted of only two entries related to family consent for continued medication, without details of the medication. An annual social service progress review for R35 was left incomplete in multiple sections, including cognitive/mental status comments, mood/behavior/emotional status, current mood and behavior status, triggers for anxiety/agitation, calming strategies, comfort foods/drinks, and psychoactive medication review. There was no documented social services follow-up after the resident-to-resident incident in December or after the February incident where R35 became physically violent with the roommate.

For R49, only one social service assessment was completed shortly after admission, and no quarterly assessment was available. That assessment was also incomplete, omitting documentation of behavior, medical and psychiatric history impact, admitting and historical behaviors or mood disorders, triggers for anxiety/agitation, calming strategies, comfort foods/drinks, daily foods/drinks, and conflict-handling style, despite the resident being on a psychoactive medication and having a very low BIMS score. Clinical notes documented that R49’s family reported verbal aggression from the roommate and requested room changes, and psych services documented ongoing depression, anxiety, agitation, verbal aggression, and threatening behavior. However, there was no social services follow-up documented after the alleged abuse incident in December, the later roommate conflict, or the psych note describing significant psychosocial distress. Interviews with the Social Service Director revealed uncertainty about how psychosocial needs and behavioral monitoring were assessed and communicated, and the Administrator acknowledged expectations for follow-up that were not met, in contrast to the facility’s policy requiring initial and quarterly assessments, documentation of medically-related social service needs, and monitoring of residents’ mental and psychosocial functioning.

The facility’s own policy on social services required the social worker or designee to complete initial and quarterly assessments for each resident, identify and document medically-related social service needs, and ensure that the care plan reflected ongoing psychosocial needs and how they were being addressed. The policy also specified services such as identifying individualized non-pharmacological approaches to meet mental and psychosocial needs and meeting the needs of residents coping with stressful events. In the cases of R35 and R49, the documented omissions in assessments, lack of detailed psychosocial and behavioral information, and absence of follow-up after resident-to-resident incidents and documented behavioral concerns demonstrate that these policy requirements were not followed, leading to the cited deficiency in providing medically-related social services to help each resident achieve the highest practicable quality of life.