Failure to Investigate and Address Neglect and Medication Documentation Deficiencies
Penalty
Summary
Facility staff failed to conduct a thorough investigation and implement comprehensive corrective actions following two separate incidents involving allegations of neglect. On one night shift, multiple dependent residents assigned to a specific staff member were found in the morning heavily soiled with urine and feces, indicating a lack of appropriate bowel and bladder care. On another night shift, a resident reported not receiving morning medications, which led to the discovery that a nurse had failed to document medication and treatment administration for a significant number of residents during her shift. Review of records confirmed that medication and treatment administration records were incomplete, and there was no verification for non-controlled medications using the facility's blister pack system. Interviews with staff revealed inconsistencies and gaps in training related to abuse, neglect, and medication administration. Several staff members reported only receiving a review of the abuse policy, with training content focused on sexual abuse rather than neglect or medication documentation. Some staff could not recall receiving any recent training on these topics, and there was confusion about the applicability and adequacy of the training provided. Documentation provided by the facility supported these accounts, showing that the abuse and neglect training materials were limited in scope and did not address the specific deficiencies identified. Further, the facility's internal processes for investigation and quality assurance were found lacking. While some staff reported informal or ad hoc meetings to discuss the incidents, there was no evidence of a formal QAPI meeting to address the quality-deficient practices or to develop needed corrections. Key staff members were not notified or included in these meetings, and documentation of required notifications to the state nursing board was delayed. No evidence was provided to show that comprehensive education on medication administration and documentation was completed for licensed staff as required.