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July Edition 2024
Welcome to our specialized update for social workers across Maryland’s LTC facilities. We have carefully compiled some of the latest health deficiencies reported by state surveyors, organized by scope and severity to help you understand and tackle the most pressing challenges in your work environment. This newsletter is designed to support you in your crucial role of safeguarding the well-being of our residents.
This edition includes selected citations related to social work from the newest CMS data release for Maryland, dated 07/31/24. Reports covering 02/02/24 to 07/31/24 were analyzed.
While our AI promptly analyzes new data swiftly after each monthly CMS update, be aware of the time gap between when citations occur and when CMS publishes them, which varies by state and CMS release.
Recent Citations Related to Social Work
Failure to Employ Full-Time Social Worker
Scope Severity Level
F
F0850
Cited on 04/18/2024
Short Summary
The facility failed to employ a qualified social worker on a full-time basis. The Activities Director had been providing social work services since November 2023, despite not being a qualified social worker. The NHA confirmed that the facility, with a capacity of more than 120 beds, had not employed a full-time social worker since the previous one left at the end of January 2024.
Corrective Actions
We did not find corrective actions in the report.
See CMS Report »
Failure to Include Residents in Care Planning and Update Care Plans
Scope Severity Level
E
F0657
Cited on 04/22/2024
Short Summary
The facility failed to include residents in care planning and did not update care plans based on current clinical conditions. A bedbound resident was not invited to care plan meetings, and another resident was unaware of any care plan meetings. Additionally, care plans for mental health diagnoses were not reviewed or updated for two residents.
Corrective Actions
We did not find corrective actions in the report.
See CMS Report »
Failure to Develop Comprehensive Care Plans for Residents on Psychotropic Medications
Scope Severity Level
E
F0656
Cited on 04/22/2024
Short Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans with measurable goals and non-pharmacological approaches for two residents receiving psychotropic medications. The care plans lacked specific behaviors for which the medications were prescribed and did not include non-pharmacological interventions.
Corrective Actions
We did not find corrective actions in the report.
See CMS Report »
Failure to Revise Care Plans and Hold Timely Care Plan Meetings
Scope Severity Level
E
F0657
Cited on 04/18/2024
Short Summary
The facility failed to revise and update comprehensive care plans within seven days after completing assessments and did not hold timely care plan meetings with residents and/or their representatives. This deficiency was identified for five residents during the recertification survey.
Corrective Actions
We did not find corrective actions in the report.
See CMS Report »
Failure to Maintain Comprehensive Medical Records
Scope Severity Level
E
F0842
Cited on 02/02/2024
Short Summary
The facility failed to ensure that primary care and specialty provider notes were placed in the medical record for review by other healthcare professionals. This deficiency affected multiple residents, including those with behavioral issues, communication problems, insulin management, and facility-reported incidents. Missing notes from psychiatric, primary care, and wound physicians were noted, hindering the ability to provide appropriate and timely care.
Corrective Actions
We did not find corrective actions in the report.
See CMS Report »
Failure to Conduct and Document Care Plan Meetings
Scope Severity Level
E
F0657
Cited on 02/02/2024
Short Summary
The facility failed to ensure timely and comprehensive care plan meetings, as well as resident participation in care planning. Several residents had no documented care plan meetings following assessments, and one cognitively intact resident was not invited to their care plan meeting. Additionally, newly admitted residents did not have documented care plan meetings after their admission assessments.
Corrective Actions
We did not find corrective actions in the report.
See CMS Report »
Failure to Develop Comprehensive Care Plans
Scope Severity Level
E
F0656
Cited on 02/02/2024
Short Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans with measurable goals and non-pharmacological approaches for several residents, including those with specific activity preferences and those receiving multiple psychotropic medications. The care plans lacked detailed interventions and targeted behaviors for which the medications were prescribed.
Corrective Actions
We did not find corrective actions in the report.
See CMS Report »
Inaccurate Documentation of Wanderguard Placement and Functionality
Scope Severity Level
D
F0842
Cited on 05/09/2024
Short Summary
The facility failed to ensure accurate medical records, as staff inaccurately documented a resident’s wanderguard placement and functionality. Despite the wanderguard being discontinued, multiple LPNs documented it as functional and in place, which was confirmed as an error by the DON.
Corrective Actions
We did not find corrective actions in the report.
See CMS Report »
Inaccurate Medical Records and Medication Documentation
Scope Severity Level
D
F0842
Cited on 04/22/2024
Short Summary
The facility failed to maintain accurate medical records for two residents. One resident was documented as using hearing aids, but observations and interviews revealed they had not worn them for months. Another resident’s medication record for Escitalopram Oxalate (Lexapro) showed inconsistencies with their documented diagnoses of anxiety and depression. The DON acknowledged the concern regarding the medication documentation.
Corrective Actions
We did not find corrective actions in the report.
See CMS Report »
Failure to Maintain Resident Dignity During Meal Assistance
Scope Severity Level
D
F0550
Cited on 04/22/2024
Short Summary
A staff member was observed standing over a seated resident while assisting them with meals, contrary to the facility’s policy requiring staff to sit. This was confirmed by the facility Dietician and discussed with the NHA, DON, and Regional DON.
Corrective Actions
We did not find corrective actions in the report.
See CMS Report »
Failure to Document Certifications of Incapacity and Guardianship Disputes
Scope Severity Level
D
F0842
Cited on 04/18/2024
Short Summary
The facility failed to document certifications of incapacity and ensure the accuracy of the MOLST form for a resident, and did not document pertinent information regarding surrogacy and guardianship disputes for another resident. These deficiencies were identified during a recertification survey.
Corrective Actions
We did not find corrective actions in the report.
See CMS Report »
Failure to Treat Resident with Respect and Dignity
Scope Severity Level
D
F0550
Cited on 04/18/2024
Short Summary
A Geriatric Nursing Assistant (GNA) dragged a resident backwards on a shower chair through the hallway due to a broken footrest, failing to treat the resident with respect and dignity.
Corrective Actions
We did not find corrective actions in the report.
See CMS Report »
Failure to Ensure Resident Dignity
Scope Severity Level
D
F0550
Cited on 04/03/2024
Short Summary
The facility staff failed to ensure resident dignity as evidenced by staff not wearing name tags and using personal cell phones during resident care. One GNA and one RN were observed without name tags, and another GNA was seen using a personal cell phone while assisting a resident with lunch.
Corrective Actions
We did not find corrective actions in the report.
See CMS Report »
Failure to Maintain Resident’s Dignity Through Proper Grooming
Scope Severity Level
D
F0550
Cited on 02/02/2024
Short Summary
The facility failed to ensure a dependent resident was groomed in a manner that preserved their dignity. Despite the resident’s dependence on staff for all self-care needs and their expressed desire to have facial hair shaved, observations showed the resident with facial hair on multiple occasions. Staff interviews confirmed the oversight, leading to a deficiency in maintaining the resident’s dignity.
Corrective Actions
We did not find corrective actions in the report.
Recent High Scope and Severity Citations