Failure to Provide and Document Required Social Work Services
Penalty
Summary
The facility failed to provide and document medically-related social services for a resident with dementia and schizoaffective disorder. The resident had a POA for health decisions and was documented in an annual social work (SW) assessment as being primarily alert to self with cognitive deficits related to place and time, as well as confusion. The annual assessment noted that the SW was available for emotional support and for concerns or complaints. A subsequent SW quarterly assessment documented that the resident continued to have severe cognitive impairment due to advanced dementia, with stable mood, calm and friendly affect, and poor insight and judgment, and stated that the SW would remain available for ongoing support, care coordination, and advocacy for the resident’s needs and comfort. The resident’s MDS showed severely impaired cognition with a BIMS score of 0 and that the resident was rarely or never understood. The resident’s care plan identified long-term care needs and psychiatric diagnoses of schizoaffective disorder and bipolar disorder, with interventions including encouraging the resident to express thoughts and feelings, providing support and validation as needed, and providing psychiatric services within the facility. Despite these identified needs and planned interventions, the clinical record lacked required SW documentation. There were no SW quarterly progress notes for an eight-month period following the last note dated 7/2/25, and no SW annual assessments for a period of one year and four months following the last annual assessment dated 11/13/24. The DNS confirmed there were no additional SW notes in the resident’s record. In an interview, the sole facility SW acknowledged that the resident’s annual and quarterly progress notes had been missed due to an oversight, noted that the electronic medical record did not prompt her to document, and stated that progress notes should be completed at least quarterly and annually. When requested, the facility did not provide a SW documentation and assessment policy.
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