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 Alzheimer’s disease, major depression, and a BIMS score of zero had no healthcare POA or guardian, while the listed financial POA declined involvement in healthcare decisions. The care plan identified impaired cognition and behaviors but did not address the resident’s capacity to consent to sexual activity, despite two separate incidents in which the resident was found partially or fully undressed in bed with male residents and engaged in sexual contact. Staff and leadership acknowledged relying solely on BIMS scores to judge consent capacity, did not complete formal assessments of sexual consent capacity, and did not document any attempts to obtain guardianship, while the Social Service Designee and PCP both stated the resident could not make her own decisions or give informed consent.
A resident with generalized muscle weakness, wheelchair dependence, and extensive ADL needs requested transfer to another facility during the initial care plan meeting, but the Social Services Director left the discharge planning section incomplete and did not send referrals or ensure follow-through. The Social Services Assistant, who was on leave at the time, was not directed to assist and only contacted another facility weeks later after the resident repeated the request. As insurance coverage ended, the resident and family agreed to discharge home but later expressed concern because the resident could not walk and no clear home health or in-home therapy services had been arranged. The NP, physician, and PT documented that the resident still required extensive therapy and had not met goals for safe discharge, while social services delayed initiating home health referrals until the day of the planned discharge, resulting in no secured home health or therapy services at that time.
A cognitively intact resident with chronic medical conditions reported having no money available for personal needs after admission, despite previously receiving higher income and being entitled to a state Personal Needs Allowance (PNA) in addition to SSI. The resident and a family member stated only $30 per month was received, and the resident reported going two years without any additional funds. The Business Office Manager confirmed the resident should receive a $130 state PNA but was not, and business office records lacked documentation of any timely inquiry or follow-up to resolve the missing PNA. The Social Services Director had not spoken with the resident about the concern and was unaware of any complaint, and the facility did not provide a policy outlining social services expectations related to such financial support.
A resident with moderately impaired cognition and a PEG tube reported that two female nurses pointed fingers and used swear words toward them during nighttime care, while denying rough physical treatment. The resident did not inform staff but told a family member, who then emailed the facility SW with concerns about rough care and verbal abuse. The SW did not review and elevate this email until returning to work several days later and was unable to confirm whether the allegations were investigated. The LNHA and Regional Clinical Director were not made aware of the alleged abuse until the SW later provided the email, despite facility policy requiring prompt reporting of suspected or alleged abuse.
The facility failed to provide required medically-related social services follow-up after an abuse allegation by a resident with dementia, Alzheimer's disease, and anxiety. The resident reported that a CNA shoved her into a chair and threw her walker, and although no injuries were observed, a subsequent care plan documented a history of false allegations and called for Social Service involvement. However, there was no Social Service follow-up to monitor the resident’s psychosocial status, despite an abuse policy requiring increased monitoring and support after an allegation and the absence of a clear post–abuse allegation procedure while a staff member was filling in for the Social Service Director.
A resident with heart failure, anxiety, depression, and moderate cognitive impairment reported an incident in which a man entered the room, touched the resident’s ankle and leg, and was believed to be attempting rape; the account later varied, and a psychiatric APRN ultimately assessed the episode as most likely a nightmare or delusion. The resident’s care plan was updated to include trauma history and interventions such as 1:1 social service visits and emotional support, and the facility received an Ombudsman allegation of rape. However, the last social service note predated the incident, there was no social service documentation addressing the allegation or the delusion, and the SW, though directed by the DNS to speak with the resident and obtaining a statement, did not document the visit or provide additional follow-up or support visits, contrary to facility policy requiring emotional support and counseling during and after abuse investigations.
Failure to Obtain Guardianship and Assess Consent Capacity for Severely Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services to ensure a resident with severe cognitive impairment had appropriate decision-making support, including guardianship, to attain the highest practicable well-being. The resident was admitted with diagnoses of Alzheimer’s disease, hypertension, and major depression, and had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. Her care plan identified impaired cognition and thought processes related to Alzheimer’s disease, with interventions such as yes/no questioning, reorientation, supervision, and consistent routines. She had a friend listed as POA for finances who, according to the facility, did not want involvement in healthcare decisions, and there was no POA for healthcare or guardian documented. The record shows that the resident was involved in two separate incidents of sexual activity with male residents. In the first incident, staff found her in another resident’s bed with both residents’ pants down, and they were separated. In the second incident, staff found her naked in another resident’s bed with a male resident, who had his fingers in her vaginal area while she lay with her legs open allowing access; both residents were again separated and placed on 15‑minute checks. The facility’s care plan for the resident included interventions for tearful episodes and crying out, and later added frequent observation and 15‑minute checks, but there was no care plan documentation addressing her capacity to consent to sexual activity. The Kardex listed behavior interventions such as distraction from wandering and behavior monitoring, but did not include the 15‑minute checks or any information about sexually inappropriate behaviors. Interviews with facility leadership and staff confirmed that there was no assessment or evaluation of the resident’s capacity to consent to sexual activity either before or after the incidents, and that the facility relied solely on BIMS scores to determine consent capacity. The DON and RN staff stated they believed both involved residents could not consent based on their BIMS scores, yet no formal consent-capacity assessment was documented. The Social Service Designee stated the resident could not make her own decisions, that the financial POA refused involvement in healthcare decisions, and that the resident needed a guardian, but there was no documentation of any attempts to obtain guardianship. She further stated that, in practice, the facility made the resident’s healthcare decisions because there was no one else to do so. The PCP reported that the resident could not give informed consent, describing a blank stare and lack of communication when questioned, and stated that the resident almost required one‑on‑one supervision due to constant ambulation, but this information had not been communicated to facility leadership. Overall, the facility failed to initiate or document efforts to secure a guardian or other appropriate decision-maker for a resident known to be unable to make informed decisions.
Failure to Provide Medically Related Social Services and Adequate Discharge Planning
Penalty
Summary
The deficiency involves the failure of the social services department to provide medically related social services and adequate discharge planning for a resident admitted with generalized muscle weakness, mobility and ADL dysfunction, and wheelchair dependence. The admission MDS documented no cognitive or communication impairment, but a need for staff assistance with most ADLs. During the initial care plan meeting, attended by a family member and documented by the Social Services Director, the discharge planning section was left incomplete, and the resident’s expressed request to transfer to another facility was not documented in the discharge planning section. The resident and family later reported that the resident had asked to be transferred on the day of admission because the resident felt the facility could not meet their needs, and that nothing was done in response at that time. The Social Services Director stated he did not complete the discharge planning section because the resident wanted to transfer and claimed he asked the Social Services Assistant to handle the transfer. However, he acknowledged that he did not send any referrals to other facilities, and the Social Services Assistant reported she had not been asked to assist with the transfer and was on leave at the time of the initial care plan meeting. The assistant stated she knew the resident had asked to be transferred but was not involved until the resident personally approached her in the hallway weeks later, at which point she arranged to meet the next day and then contacted another facility. This contact occurred 18 days after the resident’s initial transfer request and only after the resident had to repeat the request. As the resident’s insurance coverage was ending, the resident agreed to go home and then later appealed the decision, while the NP and attending physician documented that the resident remained in extensive need of therapy and was not ready for discharge home. The resident and family expressed concern about going home due to the resident’s inability to walk and the home’s physical layout, and both reported they were unaware of any in-home services arranged by the facility. The record showed the resident refused discharge unless home health services were set up and was charged private pay while remaining at the facility. The PT confirmed the resident had not met therapy goals and could not safely discharge home without continued PT. The Social Services Director admitted he had not set up home health or therapy services and had not ensured everything was in place before the planned discharge, while the Social Services Assistant acknowledged she did not request home health services until the day of the planned discharge and was unaware she could arrange them earlier, resulting in no secured home health or therapy services at the time of the attempted discharge, as also confirmed by the Ombudsman.
Failure to Ensure Resident Received Entitled Personal Needs Allowance
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary medically-related social services to ensure a resident received their entitled personal needs allowance (PNA). A cognitively intact resident, admitted in 06/2024 with diagnoses including need for assistance with personal care, cervical spinal stenosis, and chronic kidney disease, reported having no money coming to the facility despite previously receiving $800 per month before admission and then only $30 from Social Security. The resident stated that for two years in the facility he had received no money and had been told there were no additional funds. A family member also reported that the resident only received $30 per month. The resident’s Minimum Data Set showed a BIMS score of 15, indicating he was cognitively intact at the time of these reports. The Business Office Manager confirmed the resident was an SSI recipient with $30 monthly income and that he should also receive a $130 state PNA through the Department of Children and Families, but acknowledged the resident was not receiving this PNA. Business office notes showed Medicaid coverage authorized effective 08/2024, but contained no documentation of any inquiry or follow-up regarding the missing $130 PNA. The BOM stated she had discussed the reduced SSI check with the resident and family in 05/2025 but did not document the call, and the Social Services Director reported she had not spoken with the resident and was unsure whether any complaint had been received. The facility was unable to provide a policy or procedure outlining social services expectations related to this issue. Surveyor contact with the former DCF representative revealed that PNA issues could be easily corrected in the system, but the facility’s records did not show effective action or documented efforts to resolve the resident’s lack of PNA.
Failure to Timely Review and Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the failure of the facility Social Worker (SW) to timely review and act upon an email reporting alleged verbal abuse and rough care toward a resident. The resident, who had a BIMS score of 10/15 indicating moderately impaired cognition and required staff assistance with ADLs, reported that on a nighttime occasion two female nurses, one with black hair and one with reddish dark hair, pointed their fingers and swore at them. The resident denied that staff were rough with PEG tube care or caused pain and stated that only swear words were used. The resident did not report the incident to staff but informed a family member the following day. The resident’s concerned contact (CC) sent an email to the facility SW describing care concerns, including allegations of rough care and staff cursing loudly at the resident. This email was sent on 4/10/26, but the SW, who was off until 4/14/26, did not review and bring the email forward until returning and mentioning it in a morning clinical meeting. The SW could not state whether the allegations were investigated. The LNHA and Regional Clinical Director reported that they were unaware of the alleged abuse until 4/16/26 when the SW handed the email to the LNHA. This sequence of events occurred despite the facility’s Abuse, Neglect, Misappropriation Prevention Policy requiring staff to report any suspected, actual, or alleged abuse, neglect, or mistreatment to a supervisor, department head, or the administrator.
Failure to Provide Social Services Follow-Up After Abuse Allegation
Penalty
Summary
The facility failed to provide medically-related social services following an allegation of abuse for one resident. Resident D, who had dementia, Alzheimer's disease, moderately impaired cognition, and documented anxiety with fixation on staff, reported that a CNA had shoved her into a chair and thrown her walker; no injuries were observed. A care plan dated 8/29/25 identified anxiety and fixation on staff, with interventions for staff to assist the resident in developing more appropriate coping and interaction methods. After the abuse allegation was reported to the Indiana Department of Health on 2/3/26, a new care plan dated 2/4/26 documented that the resident had a history of making false allegations and exaggerations of the truth and specified that Social Service would be involved with the resident. Despite this care plan intervention, there was no documented Social Service follow-up after the allegation to monitor the resident’s psychosocial status. During interview, the Executive Director stated that at the time of the allegation a staff member was filling in for the Social Service Director and acknowledged there was no policy outlining procedures for post–abuse allegation care. The facility’s abuse policy indicated that after an allegation was voiced, the resident would receive increased monitoring and support, but this was not carried out through Social Service follow-up for Resident D.
Failure to Provide Timely Social Services After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to provide timely medically-related social services and emotional support following an allegation of abuse. Resident #1, who had diagnoses including heart failure, anxiety, and depression, had a BIMS score of 12/15 indicating moderate cognitive impairment and required extensive assistance with ADLs, transfers, wheelchair use, and bed mobility. A psychiatric APRN note documented that Resident #1 urgently reported that a man he/she grew up with came into the room on a gurney, touched the resident’s ankle and leg, and that the resident believed he was trying to rape him/her. The resident later described the alleged perpetrator as another resident, a man in his 40s with short black hair, who came into the room, touched the resident’s ankle, told the resident not to scream, and ran his hand up the resident’s leg. The APRN noted significant confusion, mild but stable anxiety, and concluded after evaluation that the resident most likely had a nightmare or delusion. The resident’s care plan was updated to reflect a history of childhood trauma and to include interventions such as social service 1:1 visits as needed for support and reassurance, encouraging family involvement and support, encouraging verbalization of feelings, and offering psych services as needed. However, record review showed the last social service note was dated 12/23/2025, with no social service documentation related to the 12/31/2025 allegation or the delusion documented by the psychiatric APRN. The facility received an Ombudsman email alleging that Resident #1 was raped, and the DNS requested that the social worker speak with the resident. Social Worker #1 confirmed speaking with the resident about the incident but acknowledged not writing a social service note and not providing additional follow-up or support visits. Interviews with DNS #2 and the Administrator confirmed that social services saw the resident after the allegation and obtained a statement, but there was no explanation for the lack of documentation or additional support visits, despite the facility’s Abuse, Neglect and Exploitation Policy directing emotional support and counseling during and after such investigations.
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