Widespread Administrative Failures Result in Immediate Jeopardy and Substandard Care
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources to attain or maintain the highest practicable well-being of each resident. Specifically, the administration did not ensure that residents on aspiration precautions were supervised during meals, resulting in Immediate Jeopardy for 33 residents. Additionally, the facility did not prevent significant medication errors, as audit reports revealed that a large number of residents did not receive multiple medications over several days, which was confirmed by staff interviews and record reviews. These failures resulted in Immediate Jeopardy and substandard quality of care for all residents in the facility. The facility also did not provide sufficient nursing staff to meet the needs of residents, as required to maintain their physical, mental, and psychosocial well-being. There were repeated deficiencies in ensuring that dependent residents received timely assistance with activities of daily living, such as bathing and grooming, with several residents reporting not having showers for weeks and being observed with unwashed hair, uncut nails, and unshaven. Furthermore, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, including failures related to hand splint use and nephrostomy tube care, which resulted in actual harm to at least one resident. The infection prevention and control program was also found to be deficient. The administrator was aware of positive Legionella results in the water system for an extended period but did not report this to the state health department, address the system issue, notify the medical director or DON, or ensure that residents with pneumonia were tested for Legionnaire's Disease. The administrator acknowledged awareness of some ongoing issues, such as insufficient staffing and medication errors, but was not aware of other care deficiencies and stated that audits were only being conducted quarterly.