cms_SD: 48
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 48 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 745 | E | 1 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and job description review, the provider failed to ensure appropriate social services involvement for six of eight residents (17, 21, 42, 49, 53, and 58) who had mental health concerns to potentially maintain their psychosocial well-being. Findings include: 1. Observation, interview, and review of residents 17, 21, 42, 49, 53, and 58's medical records during the survey revealed a lack of social services involvement related to concerns with abusive situations, incidents and investigations, behaviors, grief support, and suicidal ideation follow-up. Refer to F550, F600, F609, F610, F740, and F758. Interview on 3/27/18 at 5:25 p.m. with the director of nursing (DON) and DON support person B regarding social services revealed she: *Agreed social services coordinator (SSC) S should have been more involved with all the residents who had concerns of mental health instability and behavioral concerns. *Had not been able to identify when SSC S involvement regarding those concerns had changed. *Had not specified what her expectations from SSC S were. *Stated: -Honestly the process just got broken for them. -I did not go back and check to make sure everything was in place for them as I should have. -I learned of the concerns through SS. Interview on 3/28/18 at 8:05 a.m. with the SSC S revealed she: *Agreed: -As a SSC and resident representative she should have been involved with all the residents and their mental health concerns as delineated in her job description. -She should have had the opportunity to facilitate for the residents and families for mental health and behavioral concerns. -As a SSC her role is vital in ensuring: --Those services are carried through for the mental health well-being of the residents. --The families of those residents are comfortable and kept informed of what is in place for their loved one. *Had been involved in completing assessments, monitoring, and documenting on the residents' behaviors. -That process had changed when the changes took place with administration. -Unsure why that change had occurred. *Agreed as a SSC reviewing behaviors and monitoring them had been a vital role of in the past but she had not questioned the change. Interview on 3/28/18 at 9:25 a.m. with the Minimum Data Set (MDS) assessment coordinator confirmed she: *Had been responsible to review and complete the behavioral documentation on all the residents' MDS assessments. -The process had been that way since she became the MDS assessment coordinator. *She had not recognized a concern with the SSC S not having as much involvement in that area. *Stated Everywhere else that I have worked the SSC would have been responsible for the behavioral monitoring, assessments, and documentation for the residents. *Had reviewed that concern and process with the SSC S. -The SSC S had been okay with the current process. Interview on 3/28/18 at 3:45 p.m. with the administrator revealed he agreed the SSC S played a vital role in the process and advocacy for the residents with mental health concerns and should have been involved. Review of the interviews above with the administrative staff revealed they all agreed: *The SSC S had been considered an advocate for the residents and should have been more involved with the residents' behavioral and mental health stability monitoring. -That process had recently changed. Those changes occurred at the time of the administrative staff changes. -No one had been able to confirm or support why the process had changed. *There had been a break-down of communication and follow-through with the assessment process of the above residents. -That process had been to ensure the residents' mental health issues were addressed timely. -That process could have created a potential concern to ensure the safety and mental health well-being of those residents had been met. Review of the provider's 3/2/15 Social Services Guidelines policy revealed: *Our facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practible physical, mental, or psychosocial well-being. *The social services personnel is responsible for: -Consultation to allied professional health personnel regarding provisions for the social and emotional needs of the resident family. -Assistance in meeting the social and emotional needs of residents. -Medically related social services are provided to maintain or improve each resident's ability to control everyday physical, mental, and psychosocial needs. These services may include, but are not limited to: --Maintaining contact with family to report on changes in health. --Assisting staff to inform residents and those they designate about the resident's health status and healthcare choices and their ramifications. --Providing or arranging provision of needed counseling services. --Through the assessment and and care planning process, identifying and seeking ways to support residents' individual needs and preferences, customary routines, concerns, and choices. --Finding options that most meet the physical and emotional needs of each resident. --Providing alternatives to drug therapy or restraints by understanding and communicating to staff why residents act as they do, what they are attempting to communicate, and what needs the staff must meet. --Meeting the needs of residents who are grieving. --Finding options, which most meet their physical and emotional needs. *The social services department is responsible for: -Identifying individual social and emotional needs. -Assisting in providing corrective action for the resident's needs by developing and maintaining individualized social needs. -Compiling and maintaining up-to-date information about community health and service agencies available for resident referrals. -Maintaining appropriate documentation of referrals and providing social service data summaries of such agencies. -Maintaining contact with the resident's family members involving them in the resident's total plan of care. -Working with individuals and groups in developing supportive services for residents according to their individual needs and interests. -Participating in interdisciplinary staff conferences, providing social service information to ensure treatment of [REDACTED]. Review of the provider's revised 3/19/18 Director of Long Term Care job description for the director of nursing revealed: .The individual must demonstrate knowledge of the principle of growth and development over the life span and possess the ability to assess data reflective or the resident's status and interpret the appropriate information needed to identify each resident's requirement relative to his/her age-specific needs. The Director of Nursing is responsible for hiring and disciplinary needs within the department to include supervision of other department directors. Review of the provider's revised 12/8/17 Senior Director Long Term Care Services job description for the administrator revealed:* .The Senior Director is responsible and accountable to ensure that action plans are set in place to reach goals the organization should successfully attain for its strategy to succeed. He/she must deploy the resources and develop goals to ensure employees understand the intent of the Strategic Plan/Operational Plan. *Develops a cohesive team as demonstrated by opinion survey, department survey results, exit interview, retention strategies, operational measurements and performance measurements developed by the department . | 2020-09-01 |