Failure to Use Resources Effectively and Ensure Resident Well-Being
Penalty
Summary
The administration team failed to use facility resources effectively and efficiently, resulting in multiple deficiencies affecting resident care and safety. One resident experienced an accidental overdose when two Fentanyl patches were applied without removing the previous patch as ordered. The incident was not immediately investigated, and no interventions were implemented to prevent recurrence. The DON stated the incident was not investigated due to working on the floor and being off duty, while the Administrator was unaware of the specifics and did not ensure an investigation or follow-up occurred. Another deficiency involved incorrect physician orders for a resident's medication, midodrine, which was not properly entered into the medical record, potentially affecting the intended administration. The DON confirmed the error and acknowledged responsibility for ensuring medical record accuracy. Additionally, an allegation of staff-to-resident verbal abuse was not thoroughly investigated; the Administrator could not provide evidence of an investigation, statements, or staff education related to the incident, despite the suspension and subsequent termination of the accused CNA. Staffing shortages were also documented, with the facility consistently scheduling fewer CNAs than required by the Facility Assessment, leading to delays in residents receiving dialysis and missed scheduled showers or baths. Respiratory therapy staffing was insufficient to support ventilator weaning as ordered for a resident, and nursing staff were not trained to perform this task. Multiple interviews with staff and review of records confirmed that inadequate staffing contributed to missed care and delays in essential services.