Failure to Maintain Licensed Administrator and Oversight Resulting in Lapses in Care and Safety
Penalty
Summary
The facility failed to ensure a licensed Administrator was available and actively involved in daily operations, resulting in significant lapses in care and oversight. The Administrator position was filled by an individual who did not possess a Missouri Administrator license, and there was confusion among staff regarding who the Administrator was. Staff were unable to identify the current Administrator, and the individual serving as Administrator was unaware of key events, such as ongoing investigations into misappropriation. The facility did not have a policy related to the Administrator role, and there was no Temporary Emergency Administrator License issued. Due to the lack of effective administrative oversight, the facility did not maintain sufficient nursing staff to meet resident needs, leading to residents being left wet for extended periods and nurses working excessive shifts. Staff did not have access to necessary medications, including insulin and pain medications, resulting in residents not receiving ordered treatments. Additionally, a staff member under investigation for misappropriation was allowed to return to work, causing at least one resident to feel unsafe and consider leaving the facility. The facility also allowed an unlicensed driver to transport residents to appointments, as there was no Administrator available to address the issue when it was discovered. Interviews with staff, including the Business Office Manager, LPNs, and the Medical Director, confirmed the absence of a licensed Administrator and the resulting confusion and lack of leadership. Staff were unclear about reporting structures and who to contact in the event of issues, such as the discovery of a suspended driver's license. The lack of administrative presence and oversight directly contributed to failures in resident care, medication administration, staffing, and resident safety.