Failure to Address Staff Performance and Medication Administration Deficiencies
Penalty
Summary
Facility administrative staff failed to act in a timely and thorough manner to address concerns regarding a staff member responsible for resident care and services. Multiple staff members reported ongoing issues with this staff member, including confusion, slurred speech, calling people by the wrong name, weight loss, and wandering, over a period of three to four months. Despite these reports, administrative staff did not investigate, document, or escalate the concerns, nor did they ensure that the staff member was following facility policies. The staff member in question was involved in more than 50 medication errors, including failure to administer medications, improper glucose checks, and incomplete skin checks, affecting 11 residents. Concerns about the staff member's cognitive status and performance were not adequately addressed or documented by supervisors. Additionally, administrative staff did not identify or act on ongoing issues related to the facility's medication administration policy, procedures, or system. Medication administration records for 12 residents showed 138 missed medications, 59 missed fentanyl patch checks, and 17 missed lidocaine removals over a two-and-a-half-month period. Staff interviews revealed uncertainty about who was responsible for reviewing medication records for missed doses, and missed doses were only considered when medications were returned to the pharmacy without explanation. The facility's policies required immediate documentation of medication administration and errors, but these were not consistently followed. The deficiencies affected a significant number of residents, with ongoing medication errors and lack of proper oversight by administrative staff. The failure to investigate, document, and address staff performance and medication administration concerns resulted in continued issues with resident care and services. The administrative staff's inaction and lack of adherence to facility policies contributed to the persistence of these problems.