Failure of Administrative Oversight in Behavior Management and Medication Administration
Penalty
Summary
The facility failed to provide adequate administrative oversight and guidance to ensure that staff were aware of and implemented policies and procedures related to abuse reporting, behavior management, medication administration, and pre-admission screening. Interviews and record reviews revealed that staff did not consistently document or communicate resident behaviors, particularly those involving mental illness or behavioral symptoms, which led to incidents of verbal abuse and roommate incompatibility that were not addressed in a timely manner. Additionally, there was a lack of documented training and clear processes for staff regarding the administration and documentation of intravenous antibiotics and other medications, resulting in missed doses that were inaccurately recorded as administered. Specific incidents included staff being aware of a resident's derogatory language and behavioral issues but failing to communicate or address these behaviors until further verbal abuse occurred. There were also instances where missed doses of intravenous antibiotics were documented as given, despite discrepancies in the medication supply and lack of evidence that the medications were actually administered. The Director of Nursing and Administrator were unaware of these omissions until identified by the survey team, and there was no documented training or written protocols for staff on critical clinical procedures such as IV antibiotic administration and PICC line care. The Administrator and Director of Nursing were unable to clearly articulate their oversight responsibilities or demonstrate effective monitoring of staff compliance with documentation, behavior management, and medication administration. The lack of effective communication, documentation, and oversight created an environment where serious injury, harm, impairment, or death to residents was possible, leading to the citation of Immediate Jeopardy under federal regulations. The deficient practices had the potential to affect all residents in the facility.