Immediate Jeopardy Due to Pervasive Failures in Resident Care, Medication Administration, and Infection Control
Penalty
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.