Failure to Provide Effective Leadership, Timely Abuse Investigation, and Adequate Resident Monitoring
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in multiple deficiencies related to leadership, abuse prevention, injury investigation, and mental health monitoring. Specifically, management did not provide sufficient leadership to address or avoid concerns, including the failure to promptly investigate and report allegations of abuse. Staff were aware of a potential verbal abuse incident and reported it to the DON and SSD, but facility leadership did not immediately investigate or implement interventions to prevent further abuse, despite the issue being discussed in morning meetings. Additionally, an injury of unknown origin was not reported or investigated in a timely manner. A CNA reported a resident's swollen ankle to a nurse, who failed to follow protocol by not completing a full assessment, not inquiring about the cause, and not notifying management, the physician, or the family. The injury, later found to be a fracture, was not reported to leadership until days later, and hospital records indicated the fracture was several weeks old. Furthermore, the facility did not adequately monitor a resident with worsening depression and suicidal ideations. The resident's MDS assessments showed increasing depression scores over several months, but no actions were taken by the SSD, and there was no evidence of psychotherapy since June 2022. Interviews with staff and management revealed that while some were aware of these issues, including the abuse allegation and the resident's mental health decline, appropriate actions were not taken. The interim NHA acknowledged that some concerns had gone unaddressed and unnoticed prior to his arrival.