Governing Body Failed to Oversee Abuse, Staffing, Medication, and Infection Control
Penalty
Summary
The governing body failed to provide adequate oversight and monitoring of the facility's appointed Corporate Officers/Administrator and the Director of Nursing, resulting in multiple deficiencies. There was a failure to identify, report, and assess a pattern of abuse related to resident-to-resident altercations, particularly involving one resident, as well as a failure to address or implement interventions for potential incidents of abuse involving several other residents. Additionally, the governing body did not ensure sufficient nursing staff to supervise residents and provide timely care, which led to falls and substantial injuries for multiple residents. The facility also failed to administer medications as prescribed, resulting in significant medication errors and harm to at least one resident. The infection control program was not implemented appropriately, leading to the spread of a contagious disease that affected 27 out of 61 residents and 33 staff members. The report also notes that previous citations related to accident hazards and infection control were not sustained, as evidenced by repeat deficiencies. During interviews, facility leadership acknowledged awareness of some issues but were not fully informed about the extent of the problems until notified by the survey team.