Failure to Administer Facility Resources and Safeguard Resident Well-being
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources to ensure the highest practicable well-being of its residents. One incident involved a resident with confusion and poor decision-making who was left unattended outside in high temperatures, resulting in the resident being found unresponsive with a body temperature of 107°F, oxygen saturation of 88%, and second-degree burns. The physician was not notified for approximately 12 hours, and the resident was not transferred to the hospital for evaluation or treatment until about 24 hours after the incident. The Administrator was aware of the resident's tendency to go outside and had previously instructed staff on how to handle such situations, but was not present at the facility when the incident occurred. Another deficiency involved the facility's failure to provide physician-ordered medication and arrange necessary transportation for a resident following a stent procedure. The resident did not receive the required medication to prevent the stent from closing and missed follow-up appointments with a vascular surgeon due to the facility lacking a contract with a non-emergent ambulance transportation service. The Administrator acknowledged the absence of a transportation contract and was unaware of which or how many residents missed appointments during this period. This lapse resulted in the resident developing osteomyelitis of the foot. Additionally, the facility failed to prevent the misappropriation of resident property, specifically narcotic pain medications. There were multiple discrepancies in the documentation and handling of controlled substances, including missing medication cards, incomplete narcotic logs, and missing administration records. Staff interviews revealed that narcotics were frequently unaccounted for, and there was a lack of timely response from management when missing medications were reported. The facility's investigation into the missing narcotics was inconclusive due to missing records, and the required documentation and procedures for controlled substances were not consistently followed.