Failure to Prevent Neglect and Maintain Oversight Resulting in Immediate Jeopardy
Penalty
Summary
Facility administration failed to utilize its resources effectively and maintain oversight to prevent the neglect of a resident with severe cognitive impairment who was dependent on staff for activities of daily living. The resident was admitted with a known fall risk, as documented in the admission and fall risk evaluations, and sustained a fall that was not documented in the clinical record. There was no post-fall assessment, no physician notification, and no individualized interventions implemented to prevent further falls. The administration was unaware of the incident, and the nursing staff did not follow established protocols for incident documentation and follow-up. Further review revealed that a physician's order for a right hip and knee X-ray was entered, but the X-ray was never completed, and the results were not documented. Nursing staff placed a check mark on the treatment administration record indicating the X-ray was done, but interviews confirmed it was not. There was no formal system in place to track diagnostic orders or ensure completion and communication of results. Additionally, the resident's complaints of pain were not communicated to the nursing department, and there was no documentation of follow-up or notification to the physician regarding these complaints. Interviews with staff, including the DON, unit manager, and LPN, confirmed a lack of awareness and breakdowns in communication and documentation processes. The DON acknowledged gaps in the incident reporting and order review systems, and there was no supervisor coverage during certain shifts. The administrator was also unaware of the incident and could not find pertinent information in the clinical record. These failures resulted in the resident being emergently transferred to the hospital, where significant injuries were identified, and led to a determination of Immediate Jeopardy due to the likelihood of serious harm or injury.