Administrative Oversight Failure Leads to Deficiencies in Staff Training, Infection Control, and Staffing
Penalty
Summary
Facility administration failed to provide appropriate oversight to ensure staff orientation, education, and training, resulting in staff lacking clinical competencies necessary for safe and effective resident care. Specifically, licensed staff did not have documented competencies related to wound management and communication with consulting providers, which led to the deterioration of a wound for one resident. The Director of Nursing confirmed that no training or competencies had been completed with clinical staff, and new hires were not properly oriented or assessed for competency. The facility did not establish or maintain an effective Infection Prevention and Control Program (IPCP), including the absence of Enhanced Barrier Precautions and proper hand hygiene during wound care. There was no system in place for tracking, monitoring, or reporting infections and communicable diseases, and the facility failed to document infection data for multiple consecutive months. Additionally, the facility did not develop or implement an Antibiotic Stewardship Program and lacked a qualified Infection Preventionist to oversee the IPCP. Staffing levels were below the facility's determined minimum requirements for licensed nurses and CNAs, and the facility did not provide the services of a registered nurse for at least eight consecutive hours a day, seven days a week, without an approved waiver. Key management roles, including Assistant Director of Nursing, Unit Managers, Infection Preventionist, and Staff Development Coordinator, were vacant for an extended period, and the administrative team did not develop a plan to address these deficiencies or ensure the facility could safely meet residents' needs.