Failure to Schedule and Document Physician-Ordered Swallow Studies and Consults
Summary
The deficiency involves the facility’s failure to provide medically related social services by not ensuring that physician-ordered consultations and diagnostic tests were scheduled and properly documented for three residents. For one resident with COPD, dysphagia, and altered mental status, a physician ordered a Modified Barium Swallow (MBS) to rule out silent aspiration. Nursing notes documented that the physician made rounds, examined the resident, and issued the MBS order, and that Social Services was notified. The assigned LVN stated that the Social Services Director (SSD) was responsible for scheduling the MBS after receiving the order and that nursing did not typically follow up once the order was handed off. However, there was no documentation in the electronic medical record (EMR) that the MBS was scheduled, completed, refused, or that any follow-up attempts or contacts with the resident or responsible party occurred. Another resident with seizures, dystonia, a history of traumatic brain injury, and a gastrostomy tube had a physician’s order dated 7/22/25 for a Barium Swallow consult. Nursing notes indicated that the physician examined the resident and issued a new order for the Barium Swallow consult and that the Social Services Assistant was notified. The LVN stated that the resident had swallowing issues and received nutrition and medications via G-tube because he was not safe to eat or drink by mouth, and that Social Services should have scheduled the appointment and documented follow-up in the EMR. The Speech Therapist (ST) confirmed that this resident had an MBS ordered to assess whether he could tolerate an oral diet and reported that she followed up with the SSD months later and was told the SSD was still working on scheduling the test. The SSD later stated she had contacted the resident’s sister because the hospital required the responsible party to attend the appointment, and that she called the sister several times but did not document any of these attempts or contacts in the EMR. A third resident with hemiplegia and hemiparesis following cerebral infarction, dysphagia, aphasia, and a G-tube had physician’s orders dated 12/10/25 for an ENT consult to assist with vocal cord mobility and for an MBS to rule out silent aspiration and determine if a by-mouth diet was possible. The LVN stated this resident had been dependent on G-tube feeding on admission and had progressed to an oral diet while in the facility, and that the MBS was ordered to ensure he could safely tolerate oral intake. The ST stated she was treating this resident and that he needed an MBS to confirm he could tolerate an oral diet without aspirating and also needed an ENT consultation to help with communication. The SSD stated the resident had been scheduled for an in-house ENT consultation but discharged before the appointment, and that the MBS had not been scheduled because they were waiting for the ENT consult and insurance authorization. The SSD acknowledged she did not document the appointment, her attempts to obtain authorization, or any notifications to the ST or primary physician in the EMR. Across these three residents, the SSD described a process in which physician orders were delivered to her, sometimes placed under her office door, and she would then begin scheduling. She admitted she did not document attempts to schedule appointments or follow-up notes in the EMR, instead keeping papers with orders and handwritten notes in a folder in her office, and that when she did enter information into the EMR it was in a communication section that was automatically cleared and not part of the permanent medical record. The SSD stated that if something was not documented, it was considered not done, and acknowledged she should have documented her efforts in the EMR. The facility’s policy and procedure for Social Services referrals required Social Services to collaborate with nursing and other disciplines to arrange physician-ordered services and to document the referral in the resident’s medical record. The DON and Administrator both stated that the SSD was responsible for scheduling such appointments and that appointment scheduling and follow-up notes needed to be part of the resident’s medical record, but they were unaware that the SSD had not scheduled the ordered tests and consultations or documented her actions in the EMR. The surveyors concluded that these failures caused a delay in care and had the potential for the residents’ needs to go unmet.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with ESRD and thrombocytopenia had a physician-ordered oncology follow-up, but the referral for insurance authorization was not sent in a timely manner. SS and the CM described delays and a lack of follow-up communication, and the oncology appointment was not scheduled until much later after authorization was finally obtained.
A resident with dysphagia, COPD, depression, anxiety, a stage 2 sacral pressure ulcer, urinary retention, severe malnutrition, and cachexia had an incomplete discharge process. The SW did not complete a discharge note, and the discharge summary omitted key details such as transportation, follow-up care, pharmacy information, home health agencies, and needed DME like a wheelchair, oxygen, peg tube supplies, and foley catheter supplies. The care conference and discharge documentation also failed to accurately reflect the resident’s wounds, tube feeding needs, and urinary status.
Failure to Provide Timely Social Services After Neglect Incident: An LPN repeatedly left the unit without notifying staff and failed to administer ordered meds and tx, leading to a neglect event with multiple residents affected. Review of records for numerous residents with conditions such as DM, CHF, AFIB, seizures, dementia, chronic pain, and renal dialysis showed no social svc follow-up after the incident. Resident interviews described missed meds, late med pass, increased pain, sleep disruption, and a panic attack after omitted meds and blood sugar checks.
A facility failed to provide medically-related social services for two cognitively intact residents who were in an intimate relationship. Staff, including the SW, RCC, UM, and DA, were aware the residents were holding hands, spending private time together, and using the conference room for privacy, but neither resident had a completed Intimacy and Sexual History assessment or an intimate relationship care plan with person-centered interventions.
Failure to provide medically-related social services and psychosocial follow-up: one resident reported needing help with transition into the facility, retrieving mail and home paperwork, paying bills, and coordinating dental care, but staff were unaware of these needs after the initial admission period. Another resident was involved in a resident-to-resident altercation in which she was struck in the back, and there were no nursing or social services notes addressing her reaction or concerns afterward.
Failure to Send Requested Transfer Referrals: A resident with MDD, GAD, and chronic pain, who was cognitively intact, repeatedly asked to be transferred to a facility closer to her daughter. Social services notes showed the resident wanted referrals sent closer to home, but the requested referrals were not made for about 6 weeks. Staff interviews confirmed referrals were expected to be sent immediately or the same day if possible, and the delay was not considered acceptable.
Delayed Oncology Referral Authorization
Penalty
Summary
The facility failed to ensure a referral was sent in a timely manner to Resident 4’s insurance company for authorization to schedule an oncology appointment for thrombocytopenia. Resident 4 was admitted with end stage kidney disease and had a BIMS score of 15 out of 15, indicating intact cognition. A physician order dated February 23, 2026 directed follow-up with an oncologist for evaluation and management of thrombocytopenia, but the referral process was not completed promptly. During interviews, Social Services staff stated that when an appointment requires insurance authorization, Social Services or the Case Manager submits a referral form to the insurance company, and authorization is expected to take about three to four days. The Case Manager stated she was unsure of the exact date she sent the referral, but authorization was not received until April 23, 2026, and the oncology appointment was not scheduled until May 21, 2026. The Case Manager also stated there was a delay in requesting the authorization and that Social Services and Case Management did not have a process to follow up with each other regarding resident authorizations. The facility policy stated that Social Services personnel coordinate most resident referrals and collaborate with other disciplines to arrange physician-ordered services.
Incomplete discharge planning and social services support
Penalty
Summary
The facility failed to provide medically related social services to support the physical and psychosocial health of one resident and failed to provide advocacy for the resident’s rights during discharge planning. The resident had multiple diagnoses including dysphagia, COPD, depression, anxiety, emphysema, acquired absence of part of the stomach, a stage 2 sacral pressure ulcer, chronic pain, urinary retention, severe protein malnutrition, and cachexia. An order dated 6/11/26 indicated the resident was to discharge home with home health services for skilled nursing wound care, medication management, PT/OT, home health aide services, and DME including peg tube supplies, oxygen therapy, and a wheelchair. Record review showed no discharge note completed by the social worker and no medical provider discharge note. The care conference assessment completed on 6/3/26 did not include other disciplines, and several discharge-related items were incomplete or not checked, including tube feeding and foley catheter supplies, nutritional interventions, and resident/family education or follow-up. The nursing section also indicated the resident did not have any wounds, despite the documented stage 2 pressure ulcer. The discharge summary started on 6/1/26 was incomplete and did not document transportation, the primary provider, follow-up appointments, pharmacy information, or the agencies contacted for home care services. It selected only PT and OT for in-home care and indicated no medical equipment was needed at discharge, despite the listed need for a wheelchair, tube feeding supplies, and oxygen. It also identified the resident as continent even though the resident had a foley catheter, did not note skin integrity concerns, and did not select tube feeding as a nutritional consideration.
Failure to Provide Timely Social Services After Neglect Incident
Penalty
Summary
The facility failed to provide medically-related social services support timely after an alleged neglect event involving multiple residents. The report states that during the 3:00 PM to 11:00 PM shift, an LPN repeatedly left the assigned unit for long periods without notifying staff and did not ensure medications and treatments were administered per physician orders. Later that shift, staff found the LPN lethargic in an employee bathroom with suspected drug paraphernalia, EMS was called, the LPN was removed from the schedule pending investigation, and twenty-two residents were identified as having omitted medications and/or treatments. The event was classified as neglect. Review of social service notes from 5/21/26 through 5/27/26 for nineteen sampled residents failed to identify social worker interaction regarding the neglect incident and omitted medications. These residents included individuals with a wide range of diagnoses and care needs, such as diabetes, CHF, atrial fibrillation, seizures, dementia, depression, chronic pain, renal dialysis, and gastrostomy status. Several residents had impaired cognition, while others were documented as cognitively intact. The record review showed that the residents’ care plans included medication administration as ordered and monitoring for effectiveness, but the social service documentation did not reflect follow-up related to the incident. Resident interviews that were completed described missed medications and symptoms after the shift. One resident reported the LPN was consistently rude and called him/her crazy, leading the resident to avoid contact. Another resident reported increased pain and difficulty sleeping after not receiving medications. A resident with diabetes and insulin use reported not receiving blood sugar checks or medications, resulting in a panic attack and pain overnight. Other residents stated they could not recall whether medications were given, and several reported that when the LPN worked, medications were given very late or all at once. The DON and Regional Nurse stated that after neglect or abuse situations, all involved residents should be followed by social services daily for 3 days, and they noted there was no full-time social worker employed at the facility at that time.
Failure to Complete Intimacy Assessments and Care Plans for Two Residents in a Relationship
Penalty
Summary
The facility did not ensure medically-related social services were provided to help each resident achieve the highest possible quality of life for 2 of 4 sampled residents, R1 and R11. Both residents were cognitively intact, with BIMS scores of 15 on their annual MDS assessments, and both had diagnoses including anxiety disorder and depression for R1, and anemia, essential hypertension, and hypokalemia for R11. Survey observations and interviews showed that R1 and R11 were in an intimate relationship, were seen holding hands in R1's room and on the patio, and were using the conference room for privacy. Staff members including the RCC, UM, and DA were aware of the relationship, and the SW stated awareness that the residents had been spending more time together and getting closer. The SW also stated that intimacy and sexual history assessments were supposed to be completed on admission and that a care plan would be initiated based on the assessment outcome, but both R1 and R11 did not have completed Intimacy and Sexual History assessments. Survey review found that neither resident had a completed intimate relationship care plan with person-centered interventions. The facility's social services policy stated that the facility would provide medically-related social services to each resident and that the social worker would complete initial and quarterly assessments to identify any need for such services and document them in the medical record.
Failure to Provide Social Services and Psychosocial Follow-Up
Penalty
Summary
Medically-related social services were not provided for a resident who said he needed help transitioning into the facility and managing personal affairs. During an interview, the resident stated that after the first day or two of admission, no one had been in to help him, and he reported having no family or friends to assist him. He said he needed help getting to his home or having someone retrieve his mail, paying his insurance and household expenses, and obtaining paperwork and information from a dental appointment at home. He also stated that he had been told a tooth would be pulled and a partial plate made, and he wanted the partial denture so he could eat and chew more easily. A staff member reported only seeing the resident once shortly after admission and was unaware of the resident’s dental concerns or need for help retrieving items from home to pay bills. Psychosocial well-being was not assessed for another resident after a resident-to-resident physical altercation. Nursing documentation showed that the resident backed her wheelchair into another resident, and the other resident responded by hitting her in the back between the shoulder blades with a closed fist. A staff member stated he would talk to residents after such events only sometimes and said he was unaware that this resident had been involved in the altercation. He did not follow up with the resident regarding social service needs, and no nursing or social services notes addressing the resident’s reaction or concerns after the incident were provided by the end of the survey.
Failure to Send Requested Transfer Referrals
Penalty
Summary
The facility did not provide medically related social services to help a resident achieve the highest practicable physical, mental, and psychosocial well-being when it failed to make requested transfer referrals. The resident was admitted with diagnoses including Major Depressive Disorder, Recurrent, Unspecified, Generalized Anxiety Disorder, and Chronic Pain Syndrome, and her MDS indicated a BIMS score of 15 out of 15, showing she was cognitively intact. She repeatedly requested to be transferred to a facility closer to her daughter, her only living relative, and stated she had asked facility management over and over, spoken with social work, and written a letter asking to move closer to family. Record review showed a Social Services note at baseline care plan meeting stating the resident wanted referrals sent closer to home, and another note indicating she requested referrals be sent out and would consider other options. The resident continued to report that her request had not been followed up on for about 6 weeks. Interviews with the SSA, NHA, DON, and CNO showed the facility expected social services to send referrals immediately or the same day if possible, and staff acknowledged that a 6-week delay was not acceptable. A later Social Services note documented that 4 referrals were faxed to skilled nursing facilities and that the facility was waiting to hear back.
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