Multiple Serious Deficiencies Due to Lack of Oversight and Communication
Penalty
Summary
The facility failed to establish and implement effective procedures and clear communication methods between the administrator and the governing body, resulting in multiple serious deficiencies. The Quality Assurance and Performance Improvement (QAPI) steering committee, which was supposed to include regional and corporate leadership, did not have their attendance documented at monthly meetings for several months. The QAPI committee was also not aware of several issues identified during the survey, and there was no corporate infection control oversight in place. Deficiencies included failure to provide adequate supervision to residents on aspiration precautions during meals, with incorrect liquid consistency provided to one resident, placing 33 residents at risk for serious harm or death. There were also significant medication administration errors, with no documented evidence that all residents received their prescribed medications over multiple days, including critical medications such as insulin, antihypertensives, antiplatelets, antibiotics, and others. Staff interviews confirmed that inadequate nursing staffing led to missed medication administration for the entire resident census. Additional deficiencies were identified in the areas of resident care and infection control. One resident did not receive recommended hand splints, resulting in loss of range of motion, and another did not have orders for nephrostomy tube care for an extended period. Infection control lapses included staff failing to use appropriate personal protective equipment and perform hand hygiene during care, improper handling of catheter drainage bags, and failure to implement required measures after Legionella was detected in the water system. The facility did not notify the health department or conduct follow-up testing as required, and residents with pneumonia were not tested for Legionnaires' disease per policy.