Failure to Administer Facility Resources and Oversight of Resident Care
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources to meet the needs of all 33 residents. The Nursing Home Administrator (NHA) acknowledged that quarterly resident care conferences had not been conducted or attended by all Interdisciplinary Team (IDT) members, and there was no documentation of these conferences being completed. Additionally, the facility lacked oversight of skin assessments and wound care after the contract with an external wound care company ended, with no clear plan for ongoing wound care oversight. The NHA also reported that audits or monitoring of resident care and services were not being performed to ensure compliance, except for a one-time audit following a facility-reported incident involving a resident not receiving dressing changes as documented by nursing staff. Further deficiencies included inconsistent orientation and policy review for agency staff, with no evidence that agency staff received proper orientation or reviewed facility policies before starting their shifts. Certified Nursing Assistants (CNAs) were not receiving their required annual trainings due to the absence of a Human Resources staff member. During a resident council meeting, multiple residents reported receiving medications late or not at all, but the NHA did not investigate or report these allegations of neglect, nor did she speak with the nurse involved. The facility's policy required the administrator to ensure ongoing medical care and oversight, but these requirements were not met as described in the findings.