Failure to Administer Facility to Ensure Resident Well-Being and Safety
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources to maintain the highest practicable well-being of its residents. In one instance, a resident with Full Code status was found without vital signs, and two LPNs did not initiate CPR, failed to call EMS, and called the time of death without contacting a physician, which was outside their scope of practice. The LPNs reported that the resident's family refused life-saving measures, but investigation revealed the Power of Attorney was not present at the time, contrary to what was initially reported to the Administrator. Another resident with a history of elopement was able to leave the facility undetected by leaving her wheelchair, which had a WanderGuard, in the lobby and ambulating out the front door. Staff failed to perform required 15-minute supervision checks and were unaware these checks were still required. The incident was not reported to the State Survey Agency as potential neglect, and the DON was unaware of the elopement until the complaint investigation began. No investigation or additional interventions were implemented at the time to ensure the resident's safety. Additional deficiencies included staff refusing to provide care for a resident, resulting in delayed care, and ongoing substance use issues within the facility. One resident was reported to use crack cocaine in the building daily, with administration aware but only providing education and removing paraphernalia when found. Other residents were observed with open containers of alcohol on facility premises, despite facility policies prohibiting routine alcohol consumption. These events demonstrate failures in supervision, adherence to policy, and reporting requirements, affecting the care and safety of all residents.