Immediate Jeopardy Due to Pervasive Failures in Resident Care, Medication Administration, and Infection Control
Summary
Surveyors identified multiple deficiencies during the extended recertification survey, including failures in abuse/neglect prevention, incontinence care, quality of care, pressure ulcer management, accident hazard prevention, sufficient staffing, medication administration, and infection prevention and control. The facility did not provide adequate supervision for residents on aspiration precautions during meals, resulting in at least one resident receiving the incorrect liquid consistency as ordered by the provider. There was also insufficient nursing staff to meet residents' needs for showers, eating assistance, toileting, personal hygiene, and medication administration, as confirmed by staff interviews and record reviews. Significant medication errors were documented, with no evidence that numerous residents received essential medications such as insulin, antihypertensives, antiplatelets, antidepressants, antipsychotics, antibiotics, antirejection medications, and medications for kidney disease over several days. Medication administration audit reports revealed that large numbers of residents did not receive multiple medications on multiple days. Infection prevention and control failures included the lack of further testing for Legionnaires' disease in residents diagnosed with pneumonia, failure to implement water disinfection measures after positive Legionella samples, and failure to report high Legionella positivity rates in the potable water system to the state health department. Additional deficiencies included neglect, such as not providing recommended hand splints to a resident, resulting in lost range of motion, and leaving a resident incontinent for extended periods, leading to psychosocial harm and skin breakdown. There was also a delay in notifying a medical provider and initiating treatment for new pressure ulcers. These findings were determined to have caused or were likely to cause serious harm, with several deficiencies resulting in Immediate Jeopardy.
Penalty
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The facility failed to properly position residents during meals, affecting three individuals on the secured unit. Observations showed residents in tilt wheelchairs at inappropriate angles and one resident in a low wheelchair without leg rests, unable to reach their meal. Staff did not intervene to reposition the residents, and interviews confirmed the improper positioning. The facility's policy on dignity and respect was not followed.
Improper Positioning of Residents During Meals
Penalty
Summary
The facility failed to ensure proper positioning of residents during meals on the secured unit, affecting three residents. Observations revealed that two residents were seated in specialty tilt wheelchairs at angles between 60 to 75 degrees, with one resident's table height reaching their chin throughout the meal. The staff did not intervene or reposition the residents during the meal observation. Another resident was observed sitting in a low wheelchair without leg rests, with their feet dangling, and was not positioned properly at the table during breakfast. Despite staff presence, no intervention was made to reposition the resident to allow proper access to their meal. Interviews with staff confirmed the improper positioning of residents during meals. One staff member acknowledged that a resident was not positioned correctly at the table, citing concerns about the resident grabbing items off the table. The Director of Nursing verified that residents should be upright and properly positioned at an appropriate table height during meals. The facility's policy on Quality of Life - Dignity emphasizes care that promotes dignity, respect, and individuality, which was not adhered to in these instances.
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