Failure to Coordinate Specialist Referrals and Insurance Authorization for Resident With Gangrene
Summary
The deficiency involves the facility’s failure to carry out physician orders for orthopedic and vascular specialist consultations and to ensure appropriate follow-up for a resident with dry gangrene of the left index finger. The resident was admitted and later readmitted with diagnoses including an open wound of the left index finger, type 2 DM, and epilepsy, and was documented as severely cognitively impaired and unable to make medical decisions. The resident’s H&P indicated the need for outpatient follow-up with an orthopedic specialist to determine the need for amputation, and physician orders dated 3/13/2026 and 3/16/2026 directed the facility to obtain authorizations for orthopedic and vascular specialist consultations. Despite these orders, the consultations were not obtained in a timely manner. On observation, the treatment nurse was performing wound care on the resident’s left index finger, which appeared darkened with blackened areas at the tip, discoloration along the finger, and an enlarged fingertip. A social service note documented that the CM notified the POA that the initially identified orthopedic surgeon did not accept the resident’s secondary insurance and that another provider would be sought. An insurance prior authorization determination dated 3/18/2026 showed that the request for outpatient consultation services was returned, indicating that the resident’s primary insurance was Medicare and instructing the facility to contact the primary insurer for coverage. Interviews and record review showed that no one assumed responsibility for coordinating and following up on the referrals after the insurance issue was identified. The SSD stated she was unaware of the referral and believed the CM was handling the authorization, and there was no documentation that the SSD coordinated, scheduled, or followed up on the referrals. The CM stated she submitted an authorization request to the secondary insurance, received a response indicating Medicare was primary, believed Medicare authorization was not the facility’s responsibility, and did not follow up after the denial. RN 1 reported attempting to schedule the appointment, being told the surgeon did not accept the resident’s insurance, and then referring the issue to the CM and SSD, but did not document these attempts. The DON explained that nursing, CM, and SSD each had defined roles in obtaining referrals and authorizations and that missed communication and coordination in this process resulted in a delay of care, contrary to the facility’s job description and social services policy requiring social services staff to make referrals, obtain needed services, and ensure medically related social services are provided.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple diagnoses was affected when the facility failed to provide requested Medicaid LOC information needed to determine continuing eligibility and payor source status. KLOCS sent a lack-of-information notice, but no additional information was submitted, the request was denied, and the resident later received a discharge notice based on the denial. Interviews showed the CL handled KLOCS without formal training, the SSD had no knowledge of why the information was not forwarded, and the Administrator was unaware the denial resulted from the facility’s failure to respond.
Failure to provide ongoing psychosocial monitoring after an abuse allegation: A resident with depression and intact cognition reported that a male CNA touched her inappropriately, but after an IDT note stating the SSD would continue to follow up and provide emotional support, there was no further documentation that social services revisited the resident. The ISSD and DON stated that residents should be monitored for psychosocial distress for at least 72 hours after an abuse allegation.
A facility failed to provide medically related social services, lacked a licensed social worker, and did not complete grievance and transfer-related tasks for multiple residents. One resident with terminal cancer and another resident needing discharge to another facility did not have documented referral/transfer follow-through, discharge paperwork was incomplete, and post-discharge meds were not arranged in the record. A third resident’s grievance had no documented actions taken or written response, and the SD stated they were not a licensed SW and had limited training.
A resident with delusional disorder and moderately impaired cognition repeatedly stated a desire to leave the facility, attempted to exit multiple times, and had no active discharge plan after the original plan to return home fell through. Staff documented concerns about delusions, possible financial exploitation, and increasing confusion, but the resident was not evaluated for decision-making capacity and the facility lacked documentation of ongoing discharge planning or timely APS communication.
A resident with CHF, CAD, and a CVA had a family-requested transfer to another facility, and Social Services discussed the transfer process and faxed PRI-related documents to a prospective facility. However, the record lacked documentation of follow-up on the transfer request, the status of placement efforts, or communication of updates to the family member after the resident’s family said the resident did not feel safe in the facility.
Failure to Notify RP of Canceled Podiatry Appointment: A resident with COPD, DM, and dementia had an initial podiatry visit canceled because transportation was not arranged, but the SSC did not notify the RP or document the cancellation in social services notes. The RP later learned of the missed appointment after contacting the facility, and the resident was documented as having severely impaired cognition and no capacity to make decisions.
Failure to Provide Medicaid Eligibility Information
Penalty
Summary
Medically related social services were not provided to help a resident achieve the highest possible quality of life when the facility failed to assist with legal and/or financial matters related to Medicaid eligibility. The resident was admitted with diagnoses including muscle wasting and atrophy, chronic hepatitis C, and unspecified signs and symptoms involving the nervous system. Facility records showed that a Medicaid level of care reassessment was due, and the Kentucky Level of Care System sent a lack-of-information notification requesting additional information needed to determine the resident’s continuing eligibility and payor source status. No additional information was submitted on the resident’s behalf, and the request was denied for lack of information under Kentucky Administrative Regulations. As a result of that denial, the resident was determined not to meet the level of care needed, and the facility later issued a discharge notice stating the resident’s health had improved sufficiently to no longer need the facility’s services. Interviews showed the Clinical Liaison handled KLOCS submissions without formal training, did not recall receiving the request for additional information, and did not know why the facility never responded. The former Social Services Director stated she did not work with KLOCS and had no knowledge of why the requested information was not forwarded to Medicaid, and the Administrator stated she was unaware the denial occurred because the facility failed to submit the requested information.
Failure to Provide Ongoing Psychosocial Monitoring After Abuse Allegation
Penalty
Summary
Medically-related social services were not provided to ensure ongoing psychosocial monitoring for a resident after she reported a sexual abuse allegation. The resident was admitted with diagnoses that included depression, and her MDS showed a BIMS score of 15, indicating she was cognitively intact. On 6/24/26, the resident told nursing staff that she had been touched inappropriately by a male CNA, although she did not provide additional details about the allegation. The record showed an IDT note on 6/25/26 documenting that the previous SSD would continue to follow up with the resident to provide emotional support, but no further documentation was found showing that the SSD revisited the resident after that note. During interview, the ISSD stated that after a resident reports an allegation of abuse, the resident is monitored by social services for psychosocial distress for at least 72 hours, and the DON stated that following an allegation of abuse, a resident should have psychosocial monitoring for at least three days. The facility policy stated that social services are provided to help each resident attain or maintain the highest practicable physical, mental, and psychosocial well-being.
Failure to provide social services, transfer assistance, and grievance follow-up
Penalty
Summary
Medically related social services were not provided to help residents achieve the highest practical physical, mental, and psychosocial well-being. The facility also did not have a qualified licensed social worker on staff since 06/22/26, and the Administrator stated there was no policy related to social services. The facility’s grievance policy stated that the grievance official was responsible for overseeing grievances, investigating them, and issuing written decisions to residents, but these steps were not consistently completed. Resident #9 had diagnoses including malignant neoplasm of the esophagus with secondary malignant neoplasms of the lung and pharynx. The resident’s care plan stated that the resident and/or guardian wanted to explore other care options or living arrangements and that staff would provide information and referral to a facility of the resident’s choice. The resident and family wanted the resident closer to family, but the resident reported not hearing back from the facility about transfer arrangements or whether referrals had been sent. The family member stated they had requested referrals for about a year, had left messages for the prior social worker without response, and had spoken with the Assistant Administrator about referrals without follow-up. A CMT stated the facility did not have a current social worker and did not know who would handle such issues. Resident #11 had an order for social services as needed and was discharged to another facility, but the discharge documentation did not include key discharge details. The progress note only stated discharge to another facility and did not include mode of transfer, medications sent, or discharge instructions. The discharge recapitulation was incomplete, including the reason for discharge, discharge destination details, medication reconciliation, and whether post-discharge medications were discussed or provided. The resident’s guardian stated the resident was discharged without several medications and that nothing had been prepared in advance, and also reported that referrals to other facilities had repeatedly not been sent. Resident #10’s grievance form documented complaints about lack of communication with staff, the need for an open-door policy, no Boost supplement, and a request for a referral packet to be sent to a facility. The section for actions taken to resolve the grievance was left blank, and staff did not include a written response or any documented resolution on the grievance form. The resident stated the facility did not follow up on grievances and did not provide a copy of the grievance with any follow-up or resolution. The Social Service Designee stated they were not a licensed social worker, had not received much training from the previous social worker, and was only doing the best they could.
Failure to Ensure Safe Discharge Planning and Capacity Assessment
Penalty
Summary
Medically-related social services were not provided to help one resident achieve the highest practicable well-being because the facility did not ensure safe discharge planning or assess the resident’s decision-making capacity. The resident was admitted with a diagnosis of delusional disorder and had an admission MDS BIMS score of 12, indicating moderately impaired cognition. The resident was responsible for their own healthcare and financial decisions, but the record showed the resident wanted to return home, was told by family they were not welcome back, and had no identified place to go. The care plan noted the resident’s wishes, but the admission MDS also indicated there was no active discharge plan and that the resident declined county referral for discharge assistance. The resident repeatedly stated a desire to leave the facility and made multiple attempts to do so, including leaving with staff following one attempt and trying to exit on several other occasions. Staff interviews confirmed the resident frequently expressed wanting to leave and often attempted to leave, including through exit doors. The social services director stated the resident’s original discharge plan was to live with a family member, but that plan was no longer available, and there was no active discharge plan or referrals submitted regarding discharge planning. The facility also did not document ongoing discharge planning despite the resident’s repeated statements and attempts to leave. The record also showed concerns about delusions, financial exploitation, and possible incapacity. The resident believed a famous actor and country singer was their significant other, shared personal and financial information with another person, and staff were concerned about possible misappropriation of funds. The physician and staff discussed that the resident was increasingly delusional and altered, and the physician suspected possible underlying dementia and recommended psychiatric evaluation. The social services director contacted APS and the ombudsman about financial abuse, competency, and safe discharge options, but the facility could not provide documentation of communication with APS before the resident returned from the hospital, and the social services director confirmed the resident had not been evaluated for decision-making capacity.
Failure to Document Follow-Up on Resident Transfer Request
Penalty
Summary
Medically related social services were not fully provided to support Resident #131’s transfer request and communication with the receiving facility. Resident #131 had diagnoses including congestive heart failure, coronary artery disease, and cerebrovascular accident, and the quarterly MDS documented severely impaired memory, supervision needed for transfers from chair to bed, and family representative participation in assessment and goal setting. The resident was observed alert, awake, seated in a wheelchair, and confused, able to respond to name and engage in minimal conversation. The social services record documented that the resident’s representative requested transfer to another facility and was informed of the transfer process. The representative stated they would provide names of facilities to explore, and later the resident’s family requested that the PRI and additional required documentation be faxed to a nursing facility for review. A nursing progress note also documented that the resident’s family member reported the resident did not feel safe in the facility and requested transfer, with Social Services to be contacted for follow-up. However, the medical record contained no further documentation of follow-up on the transfer request, the status of the transfer to other facilities, or how updates were communicated to the resident’s family member.
Failure to Notify RP of Canceled Podiatry Appointment
Penalty
Summary
The facility failed to inform Resident 30’s responsible party when the resident’s initial podiatry appointment was canceled because transportation was not available. Resident 30 was admitted and later readmitted to the facility and had diagnoses including COPD, DM, and dementia. The history and physical dated 9/29/2025 stated the resident did not have the capacity to understand and make decisions, and the MDS dated 5/3/2026 indicated cognition was severely impaired and that the resident required supervision or touching assistance for all attempted mobility activities in and out of bed. During a telephone interview, the responsible party stated the Social Services Coordinator did not notify her about the missed podiatry appointment or provide updates, and that she learned about the transportation issue only after contacting the facility about a week later. Social services notes from 5/18/2026 to 6/18/2026 did not include an entry showing the appointment was canceled or that the responsible party was informed because transportation was unavailable. The Social Services Director stated it was important to document appointments and follow-up measures in social services progress notes, and the facility policy required social services staff to schedule, coordinate, and document medical appointments and to record missed or delayed appointments with the reason and care coordination details involving the attending physician and responsible party.
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