Failure to Complete Psychosocial Assessment After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with professional standards of practice. The resident was an older female with paraplegia, COPD with acute exacerbation, major depressive disorder, dementia, psychotic/anxiety/mood disturbance, and nicotine dependence. Her care plan addressed impaired cognitive function related to dementia and the need for antidepressant medication for depression, but it did not include any focus or interventions related to an abuse allegation. A quarterly MDS showed a BIMS score of 14, indicating intact cognition. On one day in November, nursing notes documented multiple interactions between the resident and LVN A. In the morning, LVN A recorded that the resident became verbally abusive and used a racial slur toward her when upset about a delayed smoke break; LVN A then requested that LVN B take the resident out for smoke breaks. Later that evening, LVN B documented a cognition/behavior/agitation event in which LVN A yelled at the resident in the hallway, told her to get off the hall and return to her room, and stated she was not the resident’s nurse and did not want her on that hall. The note indicated that arguing occurred, but that the resident and LVN A went their separate ways with no injuries, pain, or signs of distress or discomfort observed at that time. Subsequently, a nursing note by the DON documented that, after this occurrence, the resident voiced that LVN A had “popped her in the mouth.” The DON performed a head-to-toe assessment and notified the resident’s responsible party and the physician. Additional documentation by LVN B indicated no adverse skin issues and described the resident as having patterned verbal behavior with no adverse mental, emotional, or physical effects. During interview, the interim DON stated that, despite the resident’s allegation of being struck, the facility did not complete a follow-up psychosocial assessment or any risk assessments to determine whether the resident had experienced psychological harm from the event. The administrator confirmed he was unaware that a psychosocial evaluation had not been completed following the abuse allegation and that the expectation had been for the social worker to initiate such an evaluation, which did not occur.
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