Failure to Address Staff Member's Declining Performance Led to Neglect of Resident Care
Penalty
Summary
Leadership staff failed to ensure residents were free from neglect by not identifying, addressing, or correcting concerns related to a staff member's performance over several months. Staff member R was responsible for more than 50 medication errors affecting 11 residents, including failures to administer medications, complete glucose checks, and perform skin checks as required by physician orders. Despite these errors, the facility reported that no harm was found for the residents, but the required care was not provided as ordered. Multiple staff members observed and reported significant changes in staff member R's behavior and cognitive status, such as confusion, slurred speech, slowed gait, weight loss, and periods of unresponsiveness. These concerns were communicated to supervisory staff, but were not documented, investigated, or escalated appropriately. Staff member D, after receiving reports, only briefly observed staff member R and did not take further action unless she personally identified an issue. Other staff, including staff members E and L, also noted missed medications and cognitive changes but did not report or document these concerns to higher management. The lack of an effective system to track, investigate, and respond to repeated reports of staff member R's declining performance and health resulted in ongoing neglect of care for multiple residents. The facility leadership did not ensure that concerns about staff member R's ability to safely perform her duties were properly managed, leading to a prolonged period during which residents did not consistently receive necessary medications, treatments, or monitoring as ordered.