Multiple Deficiencies in Quality Assessment and Resident Care
Penalty
Summary
The facility failed to ensure its Quality Assessment and Assurance Committee effectively identified and addressed multiple deficient practices affecting resident care and facility operations. Deficiencies included the lack of clinical rationale and documentation for administering antipsychotic medication to a resident with a language barrier, failure to notify the Ombudsman and provide a bed hold policy during a hospital transfer, and the absence of a comprehensive care plan addressing communication, dementia care, and antipsychotic use. Additionally, the facility did not provide communication devices for a Spanish-speaking resident, failed to provide bathing as care planned for dependent residents, and did not ensure a safe smoking environment or use a gait belt for safe transfers, resulting in a fall. Further deficiencies were observed in the failure to post daily nursing staffing, provide non-pharmacological interventions before administering antipsychotic medication, notify a physician of out-of-range blood sugars, and follow a pureed diet recipe. The facility also did not maintain proper kitchen hygiene, including staff not covering facial hair, unclean equipment, expired supplements, and unlabeled food. There was a lack of collaboration between facility and hospice care plans, failure to offer Prevnar 20 vaccination, and maintenance issues with the walk-in freezer door. QAA meetings were held monthly and included the medical director, but these ongoing issues indicate the committee did not adequately identify or address these areas of deficient practice.