Administrative Failures Lead to Immediate Jeopardy and Repeat Deficiencies
Penalty
Summary
The facility failed to administer its operations in a manner that ensured the effective and efficient use of resources, resulting in multiple deficiencies that directly impacted resident care and safety. Leadership actions and decisions led to immediate jeopardy findings, including neglect and lack of administrative oversight. Specifically, a resident with a long-standing diagnosis of Diabetes Mellitus did not receive insulin despite being a chronic user, as documented in hospital discharge summaries and confirmed by the resident's son. The facility also failed to ensure the presence of a Registered Nurse for at least 8 consecutive hours daily over an 18-day period, and there were significant issues with medication administration, as evidenced by thousands of pages of missed and late medication reports. Additionally, 30 outstanding lab orders were not processed, and there was no documentation that providers were notified of these missed labs. Interviews revealed that the DON was frequently required to cover nursing shifts due to staffing shortages, preventing her from fulfilling her administrative duties. The DON reported being placed in the role despite being a relatively new nurse and not wanting the position, and both the DON and Administrator acknowledged that staffing shortages were impacting resident care. During an offsite review, facility leadership was unavailable to answer questions or provide information regarding a resident's care history, and there was a delay in responding to surveyor inquiries. Multiple repeat deficiencies were noted, including issues with care planning, abuse, accidents, supervision, and medical director oversight.