|Survey Date: 4/8/2009|
Regulation Title: PA-MSW-PSYCHOSOCIAL NEEDS
Regulation Description: The patient's comprehensive assessment must include, but is not limited to, the following:
(7) Evaluation of psychosocial needs by a social worker.
Based on medical record review and staff interviews, the facility failed to provide adequate social services in one (#1) of one peritoneal dialysis medical record reviewed. This failure created the potential for the psychosocial needs of the patient to go unmet.
The findings were:
The medical record for sample patient #1 was reviewed on 4/8/09. The patient was admitted to the facility on 8/27/02 and was trained to do peritoneal dialysis in his/her home. The patient customarily comes into the facility on a monthly basis for laboratory draws and appointments scheduled with his/her nephrologist.
According to the medical record, the first psychosocial assessment was appropriately performed on 9/25/02. The next documentation by the social worker was five years later dated 7/7/07 and was a Social Work Update that stated: "Call to pt. who says he is doing well. Dialysis going well. No social work needs currently." There was another note by the social worker found in the chart on the Monthly Grand Round form dated 2/11/09 which stated: "Psychosocial Needs - None Currently."
Several staff members of the facility were questioned during the survey on 4/8/09 regarding the documentation in the patient's medical record and if there was further documentation that had not been filed. According to the peritoneal dialysis registered nurse, what was filed in the medical record was all the information that was available. It was not clear during the interviews why this patient had not had another psychosocial assessment while in the facility for monthly visits or why assessments had not been performed by telephone. The social worker was not available for interview due to personal circumstances.
Facility Plan of Correction:
How deficiency has beem corrected:
Social Worker Cindy Rice completed annual psychosocial assessment on 4/10/09.
Cindy Rice, MSW
Social Worker Cindy Rice has been replaced by Ann Kurth,MSW. Facility manager located psychosocial notes from Cindy Rice dated 2-16-04, 5-5-04, 9-7-04, 2-24-06 and 7-7-07.
Pervention of future occurances:
Ann Kurth,MSW will meet with the patient monthly and document any psychosocial needs. Social Worker will document in the electronic medical record system. Center Director will monitor medical records monthly to ensure psychosicial documentation is completed.
Deficiency has been corrected as of 4-10-09