Failure to Ensure Effective Administration, Sufficient Staffing, and Timely Medication Administration
Penalty
Summary
Facility administration failed to use resources effectively and efficiently, resulting in insufficient staffing, lack of a comprehensive facility assessment, and significant medication errors. Observations over multiple days revealed delayed responses to call lights, staff appearing rushed, and residents waiting for assistance, leading to resident frustration. Facility documentation and interviews with residents and staff confirmed ongoing concerns about inadequate staffing, with reports of staffing levels below state minimums and not adjusted for resident acuity. Staff reported these issues to administration, but no changes were made, and the facility assessment did not accurately address staffing needs or the high use of agency staff. Additionally, a resident with epilepsy did not receive scheduled seizure medication on time, with a dose administered over two hours late. Subsequently, the resident experienced an active seizure and was sent to the hospital. The DNS became aware of the incident only after a family member raised concerns, and no incident report was completed, nor was the responsible LPN interviewed about the event. These failures contributed to the facility not attaining or maintaining the highest practicable well-being of residents.