Failure to Implement Psychiatric Care Policies Leads to Resident's Death
Summary
The deficiency in the facility's care was primarily due to the failure of the Medical Director to implement resident care policies and coordinate medical care for a resident, identified as R84. R84 was admitted with a Level 2 PASRR indicating a need for monthly psychiatric services, which the Medical Director was unaware of. Consequently, the facility did not provide the necessary psychiatric services. This oversight was a significant factor leading to the resident's tragic death by suicide, as the resident was found deceased with oxygen tubing wrapped around her neck. R84 had a history of major depressive disorder, schizoaffective disorder, and generalized anxiety disorder. Despite having a care plan that included interventions for these conditions, there was no documented evidence that the Medical Director or other staff followed up on missed psychiatric appointments or the resident's refusal of facility-provided psychiatric services. The Medical Director, who was also the resident's primary care physician, noted the resident's conditions as stable in several progress notes but did not address the lack of psychiatric care or the resident's refusal to engage with the facility's psychiatric services. Interviews with staff revealed that there were signs of mood changes in R84, particularly after interactions with her spouse, but these were not adequately addressed. The former Social Services Director noted a high score on the PHQ-9 depression scale for R84 but did not pursue alternative psychiatric services after the resident refused the facility's provider. The lack of communication and coordination among the facility's staff, the Medical Director, and external psychiatric providers contributed to the failure to provide necessary psychiatric care, ultimately leading to the resident's death.
Penalty
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The facility did not ensure the medical director implemented care policies, coordinated medical care, or participated in QAPI meetings. As a result, residents missed critical medical appointments due to lack of transportation, one resident developed osteomyelitis after missing follow-up care, and another experienced a fatal decline due to delayed assessment and intervention. Additionally, there was a lack of communication with a dialysis center, leading to medication errors for a resident with anemia.
The medical director did not fulfill required duties related to the coordination of medical care, implementation of facility policies, and participation in QAPI activities, as evidenced by a lack of documentation and oversight over a 12-month period. This deficiency impacted all residents in the facility.
The facility failed to ensure adequate oversight by the Medical Director, affecting all 105 residents. The Medical Director was unaware of the severity of concerns despite being part of the QAPI committee and admitted to not always providing completed documentation for resident visits. There was no evidence of the Medical Director's participation in addressing concerns or coordinating care, contrary to the facility's policy requiring periodic meetings with staff to discuss issues and solutions.
Failure of Medical Director to Implement Care Policies and Coordinate Medical Care
Penalty
Summary
The facility failed to ensure that the designated medical director implemented resident care policies, coordinated medical care, and participated in Quality Assurance and Performance Improvement (QAPI) meetings. Review of QAPI minutes and interviews revealed that the medical director did not attend or participate in QAPI meetings, and there was no documentation of attendance or involvement. Additionally, when the facility lost its contract with a non-emergent ambulance transportation service, there was no evidence of a backup plan or ongoing efforts to resolve the issue, resulting in residents missing critical medical appointments due to lack of transportation. One resident developed osteomyelitis of the foot after the facility failed to provide physician-ordered medication following a stent procedure and did not arrange necessary follow-up appointments with a vascular surgeon. The resident required cot transport, which was unavailable due to the lack of a transportation contract. Another resident experienced a significant change in condition that was not promptly assessed or treated by nursing staff, resulting in severe dehydration, acute kidney injury, and subsequent death after transfer to a hospice facility. There was no evidence that the facility identified or addressed the staff's lack of intervention prior to the survey. Additionally, the facility did not ensure proper communication and collaboration with an outside dialysis center regarding the care of a resident receiving hemodialysis. The resident had a critically low hemoglobin level and was prescribed Epoetin alfa, which was not administered as ordered due to unavailability from the pharmacy. The dialysis center was unaware of the Epoetin alfa order and administered a different medication from the same drug class. The medical director was not aware of the medication issues or the care provided by the dialysis center, and there was no evidence of coordination between the facility and the dialysis provider.
Failure of Medical Director to Fulfill Oversight and Quality Assurance Responsibilities
Penalty
Summary
The facility failed to ensure that the medical director fulfilled responsibilities related to the coordination of medical care, implementation of facility policies and procedures, and participation in Quality Assurance and Performance Improvement (QAPI) activities. Review of documentation revealed that only one medical director report was available for a 12-month period, and this report did not document any concerns regarding resident care, such as pressure areas, falls, or changes in condition. The medical director, who had been in the role since July 2024, did not identify or communicate any issues related to the effective administration of the facility or areas needing attention to ensure appropriate care and services for residents. Interviews with facility leadership confirmed the lack of required documentation and oversight by the medical director, as well as a lack of evidence of participation in QAPI or the implementation of resident care policies. The medical director agreement and facility policy outlined specific responsibilities, including oversight of medical and clinical care, policy implementation, and active involvement in quality assessment activities, but these duties were not demonstrated in practice. This deficiency affected all 54 residents residing in the facility.
Inadequate Oversight by Medical Director
Penalty
Summary
The facility failed to ensure appropriate and adequate oversight by the Medical Director, which had the potential to affect all 105 residents. The Medical Director, identified as Physician #232, was unaware of the severity of identified concerns despite being a member of the Quality Assurance and Performance Improvement (QAPI) committee. Physician #232 admitted to not always providing the facility with completed documentation related to resident visits. Additionally, there was no evidence of the Medical Director's participation in addressing identified concerns and overall coordination of resident care and services. The facility's policy, dated September 2021, required the Medical Director to meet periodically with nursing and other professional staff to discuss clinical and administrative issues, care problems, and offer solutions, which was not adhered to.
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