Breakdown in Administrative Oversight, Wound Care, Staff Vetting, and Resident Safety
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources to protect resident safety and prevent neglect. Specifically, there were significant lapses in wound care and physician oversight for two residents, resulting in one resident being hospitalized with severe sepsis due to a worsening foot wound and another resident requiring hospitalization and an above-the-knee amputation after a diabetic ulcer was not identified or treated. The facility lacked a systematic and comprehensive skin management program, which contributed to these incidents of neglect and actual harm. Additionally, the facility did not conduct required pre-employment criminal background checks, Nurse Aide Registry (NAR) checks, abuse registry checks, or personal and professional background checks for multiple staff members, including CNAs, LPNs, and other personnel. The Human Resources Director confirmed the absence of these checks and the lack of an accurate background check log. One CNA, who had been involved in multiple self-reported incidents (SRIs) for abuse allegations and had several disciplinary actions, was among those for whom no background checks were completed. These failures in staff vetting increased the risk to all residents. The facility also failed to thoroughly investigate allegations of abuse, neglect, and misappropriation. In several cases, investigations were incomplete, with missing staff interviews, lack of resident assessments, and conflicting or uncollected witness statements. Furthermore, the facility did not maintain a safe environment, as evidenced by multiple incidents of illicit drug use and possession among residents, with staff and contracted behavioral health specialists reporting ongoing substance abuse issues that were not addressed by administration. The facility lacked a policy for handling confirmed illicit substance use among residents, and there was no evidence that these or other concerns were addressed through the facility's quality assurance or QAPI program.