Oversight Deficiency Leads to Resident Elopement and Immediate Jeopardy
Summary
The report highlights a deficiency in oversight by the Governing Body of a long-term care facility, leading to a serious incident where a resident (RI #1) eloped from the facility on 02/05/2023. Despite being given psychotropic medication at 2:21 PM, RI #1 was not supervised and left through an unsecured door. An off-duty staff member encountered RI #1 on a busy road but did not provide adequate supervision, leaving the resident in an unsafe environment until another staff member returned them to the facility at approximately 4:10 PM. The Governing Body failed to guide the Quality Assurance and Performance Improvement (QAPI) committee in using root cause analysis to determine corrective actions needed to prevent similar occurrences in the future. The deficiency was deemed to have caused or had the potential to cause serious harm to all 53 residents in the facility, resulting in an Immediate Jeopardy situation. The Governing Body also neglected to ensure the facility had an acting Administrator for a period from 03/29/2024 to 04/08/2024. Interviews with Facility Owners and the Regional Nurse Consultant revealed gaps in oversight and accountability, with the Governing Body failing to provide adequate guidance and supervision to prevent elopement incidents and ensure proper staffing and security measures were in place. The facility's policies outlined the responsibilities of the Governing Body in establishing and implementing policies for facility management, including appointing a licensed Administrator accountable to the Governing Body. However, the investigation revealed shortcomings in oversight, communication, and adherence to established protocols, leading to the elopement incident and subsequent Immediate Jeopardy finding. The lack of proper supervision and failure to address security concerns ultimately resulted in the deficiency identified during the survey.
Penalty
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A facility's governing body failed to effectively oversee operations, resulting in missed medical appointments for residents due to lack of transportation, inadequate medication management, and uninvestigated misappropriation of narcotics. Residents missed critical follow-up care and did not receive prescribed medications, while staff failed to follow required medication documentation and inventory procedures. Leadership was unaware of these issues, and there was no evidence of thorough investigation or monitoring.
The facility's governing body failed to provide effective oversight and ensure compliance with financial obligations, resulting in nonpayment to key service providers such as the medical director, RD, landscaping, and spiritual care. Interviews revealed that both the administrator and board members were unaware of outstanding debts and board activities, and residents reported being denied access to their funds. This lack of oversight and management affected all residents in the facility.
The facility's governing body failed to engage in the oversight of the QAPI program, affecting all 50 residents. No QAPI meetings were held since before the last annual survey, and the Medical Director was unaware of the program's absence. The governing body did not review QAPI information or attend QA meetings, despite being responsible for these actions.
The facility failed to maintain a licensed nursing home administrator (LNHA) with a valid license, affecting all 39 residents. Administrator #280's license expired, and there was a period without a licensed LNHA until Administrator #285 temporarily filled the role. This lapse was identified through BELTSS verification and staff interviews.
The facility's governing body failed to effectively oversee operations, as evidenced by frequent turnover in the DON position and lack of involvement in QAPI meetings. Interviews revealed concerns about staffing levels and continuity of care, with an RN MDS Coordinator noting that inconsistent nursing management contributed to missed resident care issues.
The facility failed to maintain a licensed nursing home administrator (LNHA) with a valid license, affecting all residents. Administrator #1's license expired, and Administrator #2 temporarily took over until the license was renewed. This deficiency was identified through a review of the BELTSS system and staff interviews.
Failure of Governing Body Oversight Leads to Missed Care and Medication Mismanagement
Penalty
Summary
The facility failed to maintain an effective governing body to oversee its operations, as evidenced by multiple lapses in management and oversight. The governing body, which included the administrator, director of nursing, medical director, and other regional and corporate leaders, did not ensure that policies and procedures were properly implemented or monitored. QAPI meeting minutes revealed that when the facility's transportation contract was dropped, there was no backup plan in place, and no evidence of follow-up meetings or attendance records to address the issue. This resulted in residents who required cot transport missing critical medical appointments, with no documentation of which residents were affected or how many appointments were missed. Medication management was also deficient, with QAPI minutes noting that nursing staff failed to follow medication pass policies. Audits were conducted, but there was no documentation of meeting attendance or thorough investigation into the issues. One resident developed osteomyelitis of the foot after not receiving physician-ordered medication post-stent procedure and missing follow-up appointments due to lack of transportation. The administrator confirmed the absence of a transportation contract for an extended period and was unaware of the full impact on residents. Additionally, the facility failed to thoroughly investigate allegations of missing narcotics, resulting in misappropriation of controlled substances for multiple residents. Documentation and inventory records for controlled substances were missing, and staff interviews revealed that required procedures for signing in and out medications were not followed. Residents reported not receiving pain medication as documented, and staff expressed concerns about ongoing issues with missing narcotics. The governing body and regional leadership were unaware of these significant care failures, and there was no evidence of comprehensive investigation or resolution of the incidents.
Failure of Governing Body to Ensure Financial Oversight and Policy Implementation
Penalty
Summary
The facility failed to ensure an effective governing body that was legally responsible for establishing and implementing policies regarding the management and operation of the facility, including compliance with all financial obligations for the delivery of care. Record review and interviews revealed that the facility had a history of financial solvency concerns, with a previous complaint survey identifying issues under neglect and substandard quality of care. Multiple service providers, including the former medical director, registered dietitian, landscaping company, and a pastor providing spiritual care, reported nonpayment for their services over extended periods. Additionally, the Ombudsman received complaints from residents about being denied access to their funds. Interviews with the facility administrator and board members indicated a lack of awareness and oversight regarding financial obligations and board activities. The administrator was unaware of outstanding balances owed to service providers and was unsure about the frequency of board meetings. Board members themselves were either unaware of their current roles or the financial issues facing the facility, and could not provide documentation of board meetings. Facility policy stated that the governing body was responsible for oversight, budget approval, and financial stewardship, but these responsibilities were not being fulfilled, resulting in noncompliance affecting all residents.
Lack of Governing Body Engagement in QAPI Program
Penalty
Summary
The facility failed to ensure the governing body was actively engaged and involved in the oversight of the Quality Assurance Performance Improvement (QAPI) program, affecting all 50 residents. The facility had not conducted any QAPI meetings since before their last annual survey, which was completed on 11/17/22. This lack of engagement was confirmed through interviews with the facility's Administrator and the Medical Director, who both acknowledged the absence of QAPI meetings and the lack of a functioning QAPI program. The Medical Director was not informed about the absence of the QAPI program since his hiring, and the Administrator admitted to the lack of evidence for any QAPI meetings since the last annual survey. The governing body was responsible for reviewing QAPI information quarterly and ensuring compliance with the QA committee, but there was no evidence of their involvement or attendance at any QA meetings since the last annual survey. The facility's policies outlined the governing board's responsibility for the management and operation of the facility, including the establishment and implementation of a QAPI program. However, the governing body failed to fulfill these responsibilities, as confirmed by the President of Clinical Operations, who verified the absence of a QAPI program and the governing body's lack of attendance at QA meetings.
Failure to Maintain Licensed Nursing Home Administrator
Penalty
Summary
The facility failed to ensure that a licensed nursing home administrator (LNHA) with a valid license was providing supervision and leadership. This deficiency was identified through a review of the online verification system of the Board of Executives of Long-Term Services and Supports (BELTSS), the Administrator job description, and staff interviews. It was confirmed that Administrator #280, who had been serving as the LNHA of record, had an expired license during a specific period. This lapse in licensure had the potential to affect all 39 residents residing in the facility. Administrator #280 confirmed that she was notified by a BELTSS representative about the expiration of her LNHA license. During the period when her license was expired, Administrator #285, employed by the facility corporation, served as the LNHA. However, there was a gap when no licensed LNHA was serving, which was from the expiration of Administrator #280's license until it was renewed. The facility's job description for the Administrator role clearly stated the requirement for a current state license as a Nursing Home Administrator, which was not met during this period.
Ineffective Governing Body and Nursing Management Turnover
Penalty
Summary
The facility failed to maintain an effective governing body to oversee its operations, as evidenced by the lack of consistent leadership in the Director of Nursing (DON) position and insufficient involvement in Quality Assurance Performance Improvement (QAPI) meetings. The QAPI sign-in sheets for several dates revealed multiple individuals serving as DON, indicating significant turnover in this critical role. Additionally, the sign-in sheets lacked documentation of the governing body's participation in these meetings, which is a key responsibility outlined in the facility's Governing Body Policy and Procedure. Interviews with staff further highlighted the issues stemming from this instability. A physician confirmed the significant turnover in nursing management, while the President of Operations expressed concern over staffing levels. An RN MDS Coordinator reported being asked to fill in as Interim DON but stated she did not assume the responsibilities of the position and was not involved in QAPI meetings. This lack of consistent nursing management was reported to have affected the continuity of care and contributed to resident care issues being overlooked.
Deficiency in LNHA Licensing
Penalty
Summary
The facility failed to ensure that a licensed nursing home administrator (LNHA) with a valid license was providing supervision and leadership. This deficiency was identified through a review of the online license verification system of the Bureau of Executives of Long-Term Services and Supports (BELTSS), the Administrator job description, and staff interviews. The facility's census was 106 residents, and the lack of a valid LNHA license had the potential to affect all residents. Administrator #1, who had been serving as the LNHA of record, was notified by BELTSS that her license had expired. Consequently, Administrator #2, from a sister facility, temporarily served as the LNHA until Administrator #1 could renew her license. During the period when Administrator #1's license was expired, the facility did not have a validly licensed LNHA from the time her license expired until it was renewed. Administrator #2 confirmed that she served as the LNHA of record during this time and had a valid Ohio license to practice as an LNHA. The deficiency was identified as an incident of past non-compliance that was subsequently corrected prior to the survey.
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