Widespread Administrative and Care Failures Due to Leadership Instability
Penalty
Summary
The facility failed to administer operations in a manner that enabled effective and efficient use of resources to attain or maintain the highest practicable well-being of each resident. There was significant turnover in key administrative positions, with seven administrators, four Directors of Nursing (DON), and three Maintenance Directors within a year. This instability contributed to a lack of consistent oversight and failure to establish and maintain effective systems for compliance with federal, state, and local requirements. The facility did not provide evidence that administrative staff, including the Administrator and DON, had effective systems in place to timely identify and correct quality, care, and environmental concerns. Survey findings included multiple deficiencies across various domains of care and facility operations. These included failures in care planning for oxygen use, maintaining a clean and sanitary environment, proper garbage disposal, timely initiation of CPR or calling EMS, completion and documentation of showers and bathing, timely completion of physician-ordered labs, and accurate medical record documentation. There were also failures in ensuring an updated facility assessment for sufficient staffing, provision of corrective lens and vision care, complete orientation for new staff, sufficient competent staffing, and proper functioning of the quality assurance committee. Additional deficiencies were noted in monitoring resident food storage, supervision during smoking times, dating of oxygen tubing, completion of pharmacy reviews, physician notification of changes in condition, covering catheter drainage bags, and securing medications. Several of these deficiencies directly affected residents, including failure to initiate CPR or call EMS resulting in immediate jeopardy and death, lack of weekly skin assessments and documentation of change of condition and death, and failure to provide appropriate quality of care resulting in immediate jeopardy and death. The report documents that these failures had the potential to affect all residents in the facility, with specific residents identified as being directly impacted by the deficiencies.