Failure to Provide Adequate Social Services and Discharge Planning for Two Residents Discharged to Independent Living
Summary
Facility staff failed to provide medically related social services for discharge planning for two residents, resulting in discharges to independent living settings without adequate planning, IDT involvement, or guardian participation. For the first resident, who had multiple complex medical diagnoses including muscle wasting/atrophy, diabetes, CHF, atrial fibrillation, prior cerebral infarction, major depressive disorder, and moderately impaired cognition, the record showed the resident had lived in the facility for over three years and had been adjudicated incapacitated with a court‑appointed guardian authorized to make all decisions, including living arrangements. The MDS documented that the resident did not wish to be asked about returning to the community, and the comprehensive care plan last reviewed eight months before discharge indicated no plans to discharge. Despite this, the resident was discharged to what was documented as a "group home" without a documented discharge plan, without documented rationale for discharge, without a physician/provider order or basis for discharge, and without documented consent or involvement of the legal guardian. Clinical and facility documentation for this resident showed that the psychiatric NP and LCSW noted the resident talking about moving to a group home, but the physician’s recertification shortly before discharge stated the resident was appropriate for nursing home care and required significant help with ADLs, with no mention of community discharge. The social worker documented brief notes indicating discussion of discharge with the resident and the "group home" and set a discharge date, but there was no evidence of IDT care plan review or a written discharge plan identifying post‑discharge care needs, services, or goals. The discharge summary listed a group home address, noted medication reconciliation, and assigned the resident responsibility for scheduling follow‑up with a primary care provider, but left the provider’s contact information incomplete and contained no documentation of education on self‑administration of Trulicity or any other medications, despite the resident not having been assessed or trained to self‑administer injections or other medications in the facility. There was no documentation addressing access to a phone, money management, or specific community supports. Interviews with the guardian, NP, LPN, and social worker revealed that the guardian was not notified or consulted, the NP and nursing staff believed the destination was a licensed group home with medication administration and structured services, and the social worker had not verified the level of care or services at the destination, had not visited the site, and had no written description of services provided. Further investigation with the owner of the discharge destination for the first resident established that the setting was independent living apartments, not a licensed group home, and that residents were required to be independent with all ADLs, with no direct care or medication administration provided, only pill reminders and some meal prep if requested. The NP stated the resident required cueing for hygiene, assistance with medication administration, and could not effectively manage money, and that independent living was not appropriate. The guardian reported learning of the discharge only after being contacted by a hospital social worker when the resident was found on the street with belongings and brought to the ED, and stated she had never been contacted by the facility about the discharge and would have evaluated the location herself if informed. The administrator acknowledged that the guardian should have been involved and that there was no separate documented discharge plan beyond the discharge summary. The facility’s social worker job description, as reviewed by surveyors, required participation in discharge planning, development and implementation of the social care plan, involvement of the resident/family in planning goals, and regular review of discharge plans, which were not reflected in the documentation for this resident. For the second resident, who had resided in the facility for approximately three and a half years, diagnoses included NSTEMI, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes with proliferative diabetic retinopathy, cerebral infarction, need for assistance with personal care, gait and mobility abnormalities, and hypertensive CKD with stage 5 CKD/ESRD requiring dialysis. The care plan contained an active focus area indicating the resident wished to remain long‑term care at the facility. The NP’s discharge summary stated the resident was stable for discharge to a group home with home health PT/OT. However, the clinical record contained no documented discharge planning addressing the resident’s needs prior to discharge, no documentation of arrangements for medication administration post‑discharge, no evidence of medication education or training, and no documented plan for management of the dialysis access site/port. There was no documentation of medical equipment needs beyond later evidence of a hospital bed setup, no evidence that home health services referenced by the provider were actually arranged, and no IDT involvement in discharge planning other than a care plan meeting note on the day of discharge. The only social services documentation for the second resident consisted of two brief notes: one indicating the resident was interested in discharging to a group home after meeting with a group home representative, and another postponing discharge to a later date, with no details on the destination, services, or identified needs. The only document listing the discharge address was an IDT care plan meeting review form on the day of discharge, which also indicated the level of care as long‑term care and showed only nursing and social services present with the resident. The owner of the receiving facility reported that the setting provided apartments and rooms as independent living, with no assistance with daily care, no medication administration, only medication reminders and some meal prep if requested, and that the facility was not licensed as any type of medical facility. Interviews with the social worker, NP, and LPN showed that the social worker stated the resident requested discharge and that she ensured dialysis transport and owner awareness, but could not provide documentation of broader discharge planning; the NP believed the resident was going to a group home described as a small nursing home with CNAs and nurses and stated she was not aware it was independent living and felt the resident needed a group home; and the LPN unit manager believed the resident was discharging to a group home with 24‑hour care. The Director of Social Services confirmed that discharge planning was a social work responsibility and should be documented in the clinical record, which was not evident for this resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with tremors and heart failure was found to have unmet psychosocial needs after staff told them they could not spend long periods talking with reception staff and should limit social interaction to care-related matters or activities staff. The resident reported feeling depressed, confused, and isolated to their room for several days and filed a grievance stating they had been isolated and did not understand why. Social services and admissions later clarified the resident could talk to anyone in the building, but the record showed no documented psychosocial assessment at the time of the incident.
Failure to Ensure Podiatry Services for Two Residents: The SSD failed to ensure two residents with standing podiatry orders were seen for treatment of long, jagged mycotic toenails. Both residents had intact cognition, needed assistance with ADLs and hygiene/grooming, and were observed with overgrown toenails that they said were too long and uncomfortable. The SSD stated the residents were not seen because of insurance and that she forgot to schedule another podiatry appointment; the DON and Administrator stated the facility was responsible for providing the needed care and services.
A resident with adult failure to thrive, muscle wasting, and glaucoma had severe vision impairment and told staff he felt uncomfortable, that the facility was not equipped for a blind person, and that he wanted his own place. Although social services noted his interest in assisted living, the clinical record did not include a discharge care plan, and the NHA confirmed the failure to provide medically related social services.
Failure to arrange transportation for a resident’s medical appointment. A resident with cognitive intactness and diagnoses including cirrhosis, alcohol abuse, and hepatitis C missed a scheduled general surgery consult because the ride never showed up. Staff reported one transportation company could not provide the ride, another did not run on Mondays, and no alternate company was tried; the facility van was also unavailable due to repairs, and the resident had Medicaid pending.
A resident with intact cognition, diabetes, depression, and a below-the-knee amputation was observed wearing mismatched shoes after receiving a prosthetic. He stated the uneven shoe heights caused hip pain and that he had told staff and the social worker about the problem, but no one helped him obtain matching shoes. Multiple staff members, including the NA, RN, and SSD, had noticed the issue, and the DON was unsure whether the prosthetic company had been contacted about shoe wear recommendations.
Failure to Assist With Medicaid and POA Documentation: A resident with severe cognitive impairment, multiple chronic diagnoses, and private-pay admission status did not receive timely social services support for Medicaid paperwork or POA documentation. Facility staff lacked the POA paperwork on file, did not promptly initiate the Medicaid application process, and there were repeated miscommunications with the contracted representative and POA regarding bank statements, financial documentation, and an attempted emergency conservatorship.
Failure to Address Resident Psychosocial Needs After Social Interaction Restriction
Penalty
Summary
The facility failed to address the psychosocial needs of one resident who was reviewed for abuse. Resident 128 was admitted with diagnoses including tremors and heart failure and was able to make needs known. The care plan identified that the resident was at risk for adjustment issues related to loss of social support network after moving into the center, with interventions to review the impact on social involvement, provide assistance to increase social involvement, monitor medical conditions that may contribute to social isolation, and evaluate mood state or behavioral symptoms impacting social isolation. Resident 128 stated that a facility staff member told them they were talking to reception staff for too long, interfering with staff work, and that they were no longer able to speak to facility staff unless it was related to care, with excessive social interaction limited to activity staff. The resident reported feeling depressed, confused, and isolated to their room for several days before filing a grievance. The grievance stated the resident had been told by business office, nursing, and social service staff not to socialize with reception staff or others in the reception area and described being isolated for 15 days. Progress notes showed social services and admissions staff later told the resident they were allowed to greet and talk to anyone in the building, but if they wanted longer one-on-one conversations they should check with activities. Interviews with the Social Service Director and Administrator indicated social services should have assessed for psychosocial outcomes from the misunderstanding, but that assessment was not documented as having been done at the time.
Failure to Ensure Podiatry Services for Two Residents
Penalty
Summary
The facility's Social Services Director failed to ensure two residents were seen by a podiatrist for treatment of long, jagged mycotic toenails. Resident 55 was admitted with Parkinson's disease, muscle weakness, and DM, had intact cognition and decision-making capacity, and was totally dependent for personal hygiene. Resident 55's care plan included hygiene and grooming support, and the order summary showed a standing order for podiatry every two months and as needed for mycotic and/or other foot problems. Resident 67 was admitted and later readmitted with spinal stenosis, muscle weakness, and chronic kidney disease, had intact cognition and decision-making capacity, and required substantial to maximal assistance with ADLs. Resident 67's care plan also included hygiene and grooming support, and the order summary showed a standing order for podiatry every two months and as needed for mycotic toenails and/or other foot problems. During observation, both residents were found to have long, jagged mycotic toenails, and both stated their toenails needed trimming because they were too long. During interview and record review, the SSD reviewed a list of residents seen by podiatry and stated Residents 55 and 67 were not seen because of their insurance. The SSD stated it was her responsibility to ensure the residents were seen by the podiatrist and that the facility should have paid for the toenail trimming when the podiatrist last visited the facility. The SSD stated she had forgotten to schedule another podiatry appointment for the two residents. The DON and Administrator stated the facility was responsible for providing the care and services the residents needed, and the Administrator stated both residents should have been seen by podiatry.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services to Resident R29. The resident was admitted with diagnoses including adult failure to thrive, muscle wasting, and glaucoma, and the MDS indicated severe vision impairment. A social service progress note documented that the resident wanted to pursue assisted living and that social services would continue to follow, but the clinical record did not include a discharge care plan. During interview, the resident stated he felt uncomfortable at the facility, said it was not equipped for a blind person, reported he had only four lessons from the blind school, and expressed that he felt stuck and wanted his own place. The Nursing Home Administrator confirmed the facility failed to provide medically related social services to this resident.
Failure to Arrange Transportation for a Resident’s Medical Appointment
Penalty
Summary
The facility failed to provide medically related social services to help each resident achieve the highest practicable physical, mental, and psychosocial well-being for 1 of 2 residents reviewed for transportation to medical appointments, R43. R43 was admitted with diagnoses including cognitive communication deficit, cirrhosis of the liver, alcohol abuse, and hepatitis C, and the most recent MDS dated 4/30/36 showed a BIMS score of 14 out of 15, indicating cognitive intactness. R43 had a general surgery consult scheduled for 5/4/26 at 10:45 AM, but the appointment was missed because transportation was not arranged. R43 told the surveyor that the ride never showed up and that they threatened to leave the facility after transportation was not set up. Record review showed the appointment list documented the missed 5/4/26 appointment as missed due to no transportation, with [Transportation Company's Name] contacted and not responding. The Scheduler stated that transportation is arranged based on insurance, that one transportation company could not provide the ride and another could not provide transportation on Mondays, and that no other transportation company was tried. The Scheduler also stated the facility had a transportation van but would not use it if the resident did not have Medicaid, and R43 had Medicaid pending. The Business Office Manager stated Medicaid would back date and cover transportation costs, and the Nursing Home Administrator stated appointments should be scheduled timely and followed up with the transportation company. An email provided by the NHA stated the facility transportation van was in the shop from 4/16/26 to 4/30/26.
Failure to Provide Medically-Related Social Services for Matching Shoes
Penalty
Summary
Medically-related social services were not provided to help a resident achieve the highest possible quality of life when staff failed to assist him with obtaining matching shoes after he returned with a prosthetic. The resident had intact cognition and diagnoses of diabetes, depression, and an amputation. His care plan identified a self-care performance deficit related to a right below-the-knee amputation, noted that he preferred to choose his own clothing, and indicated he required moderate assistance with tub/shower transfers, bathing, and lower body dressing. The resident was observed sitting in a wheelchair wearing a black shoe with a thick sole on his right prosthetic and a grey shoe with a noticeably shorter sole on his left foot. He stated he did not have money to buy matching shoes, wished he had matching shoes, and said the difference in shoe height caused hip pain. He reported that he had told staff and believed the social worker knew about the issue, but no one had helped. Staff interviews showed multiple employees had noticed the mismatched shoes, including the NA, RN, and social services designee, but none had offered assistance before the survey. The social services designee confirmed she had not helped him obtain new shoes, and the DON stated she was unsure whether anyone had contacted the prosthetic company about shoe wear recommendations.
Failure to Assist With Medicaid and POA Documentation
Penalty
Summary
The facility failed to provide medically-related social services to assist with obtaining Medicaid application materials and Power of Attorney documentation for Resident #57. Resident #57 was admitted as a private pay resident, had severe cognitive impairment on BIMS testing, and had diagnoses including UTI, diabetes, COPD, respiratory failure, anxiety, depression, and required substantial to maximal assistance with wheelchair use. The care plan documented impaired cognitive function and thought processes. Record review and interviews showed that the resident’s admission paperwork indicated an expected primary payor source of Medicare/Medicaid, but the facility did not have the resident’s POA paperwork on file when staff later discussed financial and legal matters. A family representative attended a care conference, and the facility documented a plan to check Medicaid status, but the Medicaid application process had not been initiated promptly after admission. Email communications showed repeated exchanges among the contracted representative, POA, and facility staff regarding bank statements, Medicaid documentation, and requests for the facility to recognize and use the POA information already available. The contracted representative stated she had been working on the Medicaid application before admission and had provided documents and attempted to communicate with the facility after admission, but reported no response and later learned the facility was pursuing an emergency conservatorship. The POA stated he had not been notified about the conservatorship efforts and requested records and clarification. Facility staff acknowledged that the Medicaid application process should have been started on admission and that POA documentation should have been obtained for the resident’s records, and staff described the missed steps and miscommunications surrounding the resident’s financial and legal documentation.
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