Failure of Governing Body Oversight Leads to Missed Care and Medication Mismanagement
Penalty
Summary
The facility failed to maintain an effective governing body to oversee its operations, as evidenced by multiple lapses in management and oversight. The governing body, which included the administrator, director of nursing, medical director, and other regional and corporate leaders, did not ensure that policies and procedures were properly implemented or monitored. QAPI meeting minutes revealed that when the facility's transportation contract was dropped, there was no backup plan in place, and no evidence of follow-up meetings or attendance records to address the issue. This resulted in residents who required cot transport missing critical medical appointments, with no documentation of which residents were affected or how many appointments were missed. Medication management was also deficient, with QAPI minutes noting that nursing staff failed to follow medication pass policies. Audits were conducted, but there was no documentation of meeting attendance or thorough investigation into the issues. One resident developed osteomyelitis of the foot after not receiving physician-ordered medication post-stent procedure and missing follow-up appointments due to lack of transportation. The administrator confirmed the absence of a transportation contract for an extended period and was unaware of the full impact on residents. Additionally, the facility failed to thoroughly investigate allegations of missing narcotics, resulting in misappropriation of controlled substances for multiple residents. Documentation and inventory records for controlled substances were missing, and staff interviews revealed that required procedures for signing in and out medications were not followed. Residents reported not receiving pain medication as documented, and staff expressed concerns about ongoing issues with missing narcotics. The governing body and regional leadership were unaware of these significant care failures, and there was no evidence of comprehensive investigation or resolution of the incidents.